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CIHM 

Microfiche 

Series 

(l\/lonographs) 


ICIVIH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiq 


ues 


-inn 
I 


Technical  and  Bibliographic  Notei  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  <o  obtain  the  best  original 
copy  available  for  filming.   Featxres  of  this  copy  which 
may  be  bibtiographically  unique,  which  may  alter  any 
of  the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming,  are 
checked  below. 


D 
D 
D 

n 

D 
D 

n 

D 
0 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagee 

Covers  restored  and/or  laminated/ 
Couverture  restauree  et/ou  pellicula 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
I  Relie  avec  J'autre^  documents 

Tignt  binding  may  c^use  shadows  or  distortion 
along  interior  margin/ 

La  reliure  »err^  peut  causer  de  ('ombre  ou  de  la 
distorsion  le  long  de  la  marge  intcrieure 


D 


Blank  leaves  added  during  restoration  may  appear 
within  the  text.  Whenever  possible,  these  have 
been  omitted  from  filming/ 
1)  se  peut  que  certaines  pages  blanches  ajouties 
lors  d'une  restauration  apparaitsent  dans  le  texte, 
mais,  lortque  cela  itait  possible,  ces  pages  n'ont 
pas  M  filmtes. 


L'Institut  a  microfilmc  le  meilleur  exemplaire  qu'il 
lui  a  ili  possible  de  se  procurer.   Les  details  de  cet 
exemplaire  qui  sont  peut-itre  uniques  du  point  dc  vue 
bibliographique,  qui  peuvent  modifier  une  image 
reproduite.  ou  qui  peuvent  exiger  une  modification 
dans  la  m^thode  norirale  de  f  ilmage  sont  indiques 
ci-dessous. 


Th« 
tot) 


□  Coloure( 
Pages  de 


Coloured  pages/ 
couleur 


□  Pages  damaged/ 
Pages  endommag^s 

□  Pages  restored  and/or  laminated/ 
Pages  restauries  et/ou  pellicul6es 

0Pagss  discoloured,  stained  or  foxed/ 
Pages  decolortes,  tachetees  ou  piquee* 


0 


Pages  detached/ 
Pages  detach^es 


The 
posi 
of  t» 
film! 


Orig 
begi 
the  I 
sion, 
otha 
first 
tion, 
or  ill 


I     ~|  Showthrough/ 
I  ^   I  Transparence 


D 
D 


Quality  of  print  varies/ 
Qualite  in^gale  de  I'impression 

Continuous  pagination/ 
Pagination  cominue 

Includes  index(es)/ 
Comprend  un  (des)  index 


The  I 
shall 
TIIML 
whic 

Map) 
diffei 
entiri 
begir 
right 
requi 
meth 


Title  on  header  taken  from:/ 
Le  titre  de  I'en-tCte  provient: 


□  Title  page  of  issue/ 
Page  de  titre  de  la  livraison 

□  Caption  of  issue/ 
Titre  de  depart  de  la 


r— 11^ 

I I  Ge 


depart  de  la  livraison 

Masthead/ 

Generique  (periodiques)  de  la  livraison 


Additional  comments:/ 


^       „ Various  pagings.      page  *6I   is  a  photoreproduction.  Copy  has  manuscript  ri.inotati< 

I  ^    I  Commentaires  supplementaires: 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  f  ilme  au  taux  de  reduction  indiqu^  ci-dessous. 

14X  18X 


10X 


22X 


26  X 

30X 

1 

J 

12X 


16X 


20X 


24  X 


28  X 


32  X 


'il 
!t 

c  vue 

on 
s 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Osier  Library, 
McGill  University, 
Montreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Origino!  copi«9S  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impree- 
sion.  or  the  back  cover  when  appropriate.  All 
other  originei  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  ^«^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


L'exemplaire  film^  fut  reproduit  grdce  i  la 
g6n6rosit6  de: 

Osier  Library, 
McGill  University, 
Montreal 

Les  images  suivantes  ont  4t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet«  de  I'exempleire  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
pepier  est  imprim^e  sent  filmis  en  commencant 
par  te  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'iilustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
origineux  sont  filmte  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'iilustration  et  en  terminant  par 
la  derniire  page  qui  comporte  une  teile 
empreinte. 

Un  dee  symboies  suivants  apparaitra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbols  — ^  signifie  "A  SUIVRE  ",  le 
symbole  V  signifie  "FIN  ". 

Les  cartes,  planches,  tabieaux,  etc..  peuvent  etre 
film^s  d  des  taux  de  reduction  diffdrents. 
Lorsque  le  document  e&t  trop  grand  pour  dtre 
reproduit  en  un  seul  cliche,  il  est  film*  d  partir 
de  Tangle  supArieur  gauche,  de  gauche  d  droite, 
et  d^  haut  en  bas,  en  prenant  le  nombre 
d'imeges  n^cessaire.  Les  diagrammes  suivants 
illustrent  la  m^thode. 


ipt  annotatloiii, 


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COLLECTED  REPRINTS 


SECOND  SERIES. 


(January  1st,  1882-January  1st.  1892.) 


n 


V: 


-l;:. « 


•^     WILLIAM  OSLKR,  M.I).    F   R   (^  p     r 

'ospital,   liallimore. 


'he  John-   nr       n  ''■'''■'''  ""'^  Av^^ctan-m-CT^/ /o 


'I  J 


Ml 


>^' 


X 


■i 


TITLES   OF   PAPERS. 

( Cimtinued  from  Series  I. ) 


m^^ 


iWc 


XLIV.    Kti..Io,iryan.l  Pathology  of  Ulcerative  En.locanlitis. 

VT^r    rp,     ,,     .  '^^''"'O'-  J^"f(^rnaf.3ft',l.  Congress,  1881. 

aL\.    Iho  Brains  of  Criniiiials. 

Can.  Medical  and  Surgical  Journal,  1882. 
Al.\  1.    Obliteration  of  Portal  Vein. 

vr  XMr  .T     •^"'"■""^  'f/'  ^l""'o'«i/  «"f^  P/n/sioloqy,  London,  1882. 

AL\  11.  I  eber  der  d.itten  Formbestandthoil  des  Bhites. 

vr  A-rrr  GeniralbluH  f.  d.  Med.  Wissenschaften,  Berlin,  1882. 

vr    I  f;'"""^^'-«^'^-^i<'»C'linics-four articles.    Montreal,  1882. 

•  ALiX.  Lestode  Tuboroulo.sis. 

Am.  Vet.  Review,  New  York,  1882, 
L.    file  Antiseptic  Treatment  of  Empyema. 

,-.     ^^  Medical  Neivs,  1882. 

\A.    Uraemic  Delirium  and  Coma. 

^,^     ^  Archives  of  Medicine,  1882. 

LI  I.    Parasites  of  the  Blood  of  the  Fro<r 

-.  -„     ^,  Canadian  Naturalist,  1882. 

LI  11.    Cana.lian  Fresh  Water  Polyzoa. 

Canadian  Naturalist,  1882. 
■   LI\  .    Parasites  in  Pork  Supply  of  Montreal. 

Can.  Med.  and  Stirg.  Jour.,  1883. 
LV.   Clinical  Lecture  on  Hodfjkin's  Disease. 

Can.  Med.  and  Surg.  Journal,  1883. 
LVL    Preataxic  Tabes  dorsaiis.  Medical  News,  1883. 

LVII.   The  Third  Corpuscle  of  the  Blood. 

TTTTTr     XT  ,  ,,  Medical  News,  188H. 

LVIU.    Natural  Modes  of  Cure  in  Empyema. 

New  York  Medical  Record,  1883. 


:     A 


LyiX.    Study  of  tlie  Brains  of  Kicbanls  and  O'Hoiirke. 

^  (^111.  }fi(l.  (111(1  Siifff.  Joiiniaf,  IH.S,'), 

LX.   Studies  of  Clinical  ('hhv. 

(ydii.  Mctl.  and  Sun/.  Joiiriidi,  1885, 
LXr.   On  Jacksonian  Kpilcpsy. 

Americim  .loitninl  of  Mrdicdf  Scimret',  188'). 
LXII.    f]cliinococeus  Disea.-c  in  America. 

Ameripdti  .louimil  of  Medical  SricneeK,  188L. 
LXIir.   fiiiI.«tonian  Leetures  on  Endoearditii*,  delivered  at  the 
Ivoyal  ("dlietre  of  Pliysieians,  London. 

lirllish  Mnllcdl  Journdl,  1885. 
liXIV.    The  Morhid  Anatomy  of  Pneumonia. 

Cdii.  }[id.  and  Surg.  Journal,  1885. 
LXV.    The  ]\Iorl)id  Anatomy  of  Typhoid  Fever. 

Cdii.  ^f(d.  diid  Sur//.  Journal,  1885. 
LXVI.    Diseases  of  the  Suhstan('(>  of  the  Heart. 

Pc/tjier^K  Sj/.ite)ii  of  Medicine,  1885. 
LXVII.    Difsease.s  of  the  Mamatopoietic  System. 

I'ljiper.'i  SijKtem  of  Medicine,  1885. 
LXVIir.    On  the  Growth  of  a  I'rofe.^sion.     Presidential  addres.s, 
Canada  i\[ediea I  A.'isociat ion. 

Medical  Xcnv,  October,  1885. 
LXIX.    Retro-peritoneal  Sarcoma. 

Med.  Nen:^,  Mar.  Oth,  188().     Trdn.^.  Path.  Soc,  Phila. 
LXX.   Atrophy  of  the  Stomach  (primarv). 

American  Journdl  «/'  Medical  Sciences,  188(>. 
LXXI.   Cartwright  Lectures  on  the  Blood.     Delivered  at  the 
College  of  Physicians  and  Surgeons,  New  York. 

Med.  Xetvs,  and  Med.  Record,  1880. 
LXXIL   Bicuspid  ('ondition  of  the  Aortic  Valves. 

Tran>^.  Axxo.  American  Pliysician,%  1880. 
LXXIIL    Use  of  Arsenic  in  certain  forms  of  Anaemia. 

Therapeutic  Gazette,  1886. 
LXXIV.   On  Duodenal  Fleer. 

Can.  Med.  nnd  Sur(j.  JournnI,  1880. 
LXXV.   On  Cerebral  Aneurisms. 

Can.  Med.  and  Sure/.  J  I.,  1880.      TrauK  Path.  Soc,  Phila. 
LXXVr.   The  Hamatozoa  of  Malaiia. 

Ilritixh  Medical  Jourudl,  1887. 
LXXVII.    On  Antifebrin.  Therape.tic  Cazclfe,  1887. 


LX.N 

LN 

v..*»-        L] 
LX 

Lx: 

LXX 
LXX 

li^  •^'■,\  Lx: 

LXX 

.     Lxx: 

1 

LXXX 
LXX 


X 
X 

X 
X( 

xc^ 

X 


LXXVIIl. 

LXXIX. 

I  A' XX. 
I.XXXI. 

lAXXII. 

I. XXXIII. 

LXXXIV. 

|vv*i»\\    LXXXV. 

LXXXVI. 

LXXXVII. 

LXXXVIII. 


The  ( iirdiMc  Relations  of  Choreii. 

Amerinin  JoiirtutI  of  Mfdlraf  Srlence.y,  1887. 
Nott«  oil  Hut'iiioiilui^Mc  Iiifart'tif)!!. 

TmnK.  Amo.  Amer'mitt  P/n/.nri(nis,  1887. 
Oil  Cliorfa;  two  Lt-ctiirey.  McdirAtl  Newn,  1887. 

Case  of  Chole.steaoiiia.  'f 

Joiini'i/  of  N,'rr<>u.'<  and  Mciila/  I)imti^e,'<,  1887. 
Ilereditarv  A ii^io- Neurotic  Oedema. 

American  Joiirnn/  of  Medico/  Srifiicri*,  I8«8. 
Nitni-Olvceriiic  in  lOpilcp.^iy. 

■  loiiniol  of  Xrrroux  and  Menial  Dixeases,  I8^<(S, 
On  (lie  Diasxiiosis  of  Sniall-pox. 

Medical  Staitdord,  ("liicajro,  1888. 
(ilioiiiii  of  Mediill;!. 

Jonriiid  (,f  AV/-(v»(/.s  oitd  Menial  iJineaxex,  1888. 
The  Cerebral  Palsie^i  of  Children.     Three  Lectures. 
Medical  News,  188s.     Pnhl itched  also  in  London,  as  a 
Mono(jntj)li,  Issit. 
Ca.-<e8  of  I)i«>ase  o(  the  Caeciiiii  and  .Vppendi.x. 

Medical  and  Snccfieal  Heporter,  1888, 
l*ost-rarluni  Aii:ii  mia. 

Ildstoii  Mediral  and  Snr(/icai  Jonrnal.  1888. 
Tiic  l)iaj,'no.-*i.s  of  Duodenal  I'lcer. 

Xen<  York  Medical  Record,  1888. 


LXXXIX. 

.,      '       XC.    On  racliynK'iiini:i!is  IlaenKirrhii^rica. 

Medical  Xeivs,  1888. 
XCI.    Lesions  of  the  Caiila-('(|uiiia.  .}fedical  Nnr.'i,  1888. 

XCII.    On  a  Form  of  i'urpnra. 

Xew  York  Medical  Joan  tl,  1888. 
XCin.    On  the  Mortality  of  I'neiiiuonia. 

University  Medical  Magazine,  188i). 
XCIV.    On  IMiagocytes.     A  Lc-ture.  Medical  News,  1880. 

XCV.    Filsating  Pleurisy. 

American  Journal  of  Medical  Sciencen,  1889. 

XCV  I.    The  Lio-nse  to  Practice.  (An  Address),  1889. 

XCVir.    Kquanimitas.    A  Valedictory  Address  at  the  University 

of  Pennsylvania,  Phila.,  May,  1889. 

XC'VIII.    Aberrant  Thyroid  Tninoiv.  Mediral  News,  1889. 

X(TX.    Idiopathic  Mii.sciilar  .Atrophy. 

American  Journal  of  Medical  Sciences,  1889. 


)|t| 


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0 

< '.    Syphildma  »t'  (  unl  mikI  ( 'itii(lii-c<|iiiiia. 

•I'X'l'IKll  oj  Xn-VOHs  ,1)1(1  Mflitill  /»i.^>;i.^,.i,   \SH[i. 

CI.    |)iii<rii()8is  (.'(■  ^fiilaria. 

The  .loluix  Hojikiiix  lln^iiilnl  Ihilleliti,  S,>.  1,  |,H<S!). 
<II.    I|.'|)atic  InlcrMiitlciit  Ft-vcr. 

T/ir    .Iiihii.'^     JIi)jj/.in.-<     Iloyiifii/     fujiorls,     \'o\,     J  J 
Nil.  1.  1«!>0. 
<'IIf,    I'ost-Kthrile  Irisaiiity.  /A/-/,  1,S!M», 

('I\.    liarv  Korriis  oJ'Caidiac 'I'liroiiilii.  J/jiil.\S>tH 

('\'.    i;iu|,,canliiis  in  I'litliisi,-.  //^/,/    |,sj(,) 

<'\'l.    'ruhcrciilar  I'tTitmiids. 

Ti(,'    Johns    Hojik-ins    llo.tpH,,!    lU/,„rf-<.    \\>\      || 
No.  -1,  I «!»(). 
CyjJ.    Aciitt' i\e|ilinti!<  in  'JVpluiid  Fever.  /,'wV/.,  |,S!)(j. 

CV'IJI.    On  Anidlta  Coli  in  Dyseiiterv. 

The  Johm  Jlopkina  Hospital  Bnlleli,,,  N'ol.  1,  N,,.  r,,  |«(„, 
'        ^^^    ()ii  Convulsive  Tic.  Medlml  News,  \m). 

ex.    Sen.sorj-  Aplia.sia. 

•■'•"^''I'inni  'h'<i null  of  Medical  Seience.%\m\. 
CXI.    Kii(i(,l|ili  \'iieliu\v;  an  Address. 

Ilostoii  MedienI  and  S,(rr/icalJoiir)iaL  1891 
'     CXII.    On  Diagnosis  of  TubereuiousBrondiu-l'neiimonia. 
. , V , , T     T^  Archived  of  Ptdinlries,  1 «!» 1 . 

-v         J^"^*'"-  '""*  >"'"'-'*^-     (An  A,idre.ss.)     Baltimore,  1891 
tAI\  .    Hereditary  Cliurea. 

^'/"'  -/'Vt/;,>>  //oy>/.-//,.s.  y/o,s;/;//a/  JJu/letin.  1891 
<- A\  .    (.eneral  Bronchiectasis  of  Left  Lung.  Ibid    1891 

rK^vM     ^  l'''^'"^'-'""  «^' ^^'^  Si'porior  Vena  Cava.      /6,W.'|  I89l" 
*-  A  \  II.    C  ase  <.f  Multiple  8ub-Cutaneou.s  Cysticerci. 

<^  ^Vlli     ,  I  j,  Ibid.,  1891 

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m  SOME  POINTS 


1^ 


THE  ETIOLOG^^  AND  PATHOLOGY 


Of 


TJLCEllATIVE   ENDOCARDITIS 


BY 


WILLIAM  OS[.ER,  M.D. 


MONTKEAL 


■s       ■Ml 


I 


I 


LONDON 

J.  W.  KOLCKMANN,  2,  LANGIIAM  PLACE 

1881 


fm 


^uffantstw  PW* 


riAI  I.ANTVNE,  HANSON  ANn  CO.,  KDINDURGH 
CHANDOS  STKEET,  LONDON 


\m 


ON 


SOME  rOINTS  IN  THE  ETIOLOGY  AM)  PATHOLOGY 
OF  ULCEEATIVE  ENDOCARDITIS. 


Ulcerative,  infectious,  or  diphtheritic  endocarditis  is  an  affection  of  unusual 
interest  to  tlie  profession,  both  on  account  of  the  serious  nature  of  the  maladv 
which  It  excites  and  of  the  illustration  which  it  offers  of  many  po  ntsin  the 
pathology  of  infective  processes.  ^  ^  ^^'^ 

Ulceration  loss  of  substance,  on  the  endocardium  occurs  under  a  variety  of 
conditions.     Clinically  we  should,  I  think,  recognise  three  classes  of  els 
Jnrsf   those  m  which  the  disease  appears  without  any  obvious  cause   eX 
spontaneously  or  in  connection  with  rheumatism  or  some  other  affec  io7  as 
pneumonia,  chorea,  &c.    These  cases  present  a  remarkable  set  of  symptoms  ^erv 
variable  in  character,  but  of  which  two  chief  types  have  been  recojnised-the 
yphoid  and  the  pyemic     This  is  the  preliminary  form  of  some  writers.    LoZt 
those  cases  which  arise  during  the  existence  of  some  local  inflammatory  proce  s  as 
puerperal  endometritis,  acute  necrosis  of  bone,  .fee,  and  in  which  the  endocardit' 
IS  usually  regarded  as  part  of  a  pya^mic  state  and  secondary  to  the  local  Zeae 
And,  tku'd  the  cases  of  ulcerative  affection  engrafted  upon  valves  the  sub     t  of 
chronic  sclerotic  changes.    In  this  latter  variety  no  special  symptoms  necessari^ 

XTlet.'"""'  ''''  '''''^''  '''  "^'^^"^  "^  *^^  '^'^'^^^  ^^^ 
I  propose  to  consider  briefly  in  the  following  paper  some  of  the  conditions 
under  which  the  disease  arises,  some  points  in  the  morbid  anatomy  and  h  tlv 
make  a  few  remarks  on  the  supposed  relation  of  micrococci  to  the  disease ' 

0/  the  conditions  under  which  the  disease  is  met  with.- {a.)  Rheumatic  feve,- - 
I  IS  very  genera  ly  stated  by  writers  on  the  subject  that  the  "  great  mi-or!ty  » 
of  the  cases  of  the  ulcerative  form  of  endocarditis  occur  durin^  the  course  nf 
this  affection.  While  it  undoubtedly  holds  good  that  the  vo"ruc!t  or "  h' tic 
variety  is  met  with  most  frequently  in  patients  the  subjects  of  rheumatism' mv 
own  experience,  as  well  as  an  examination  of  the  literature,  leads  me  S  believe 
that  the  above  statement  requires  reconsideration.  Of  twelve  cases  of  the  acute 
primary  form  which  have  come  under  my  observation,  in  only  three  was  the  e 
any  history  o  rheumatism,  and  in  all  only  as  indefinite  painful  condition  of 
he  joints,  not  as  acute  rhe,  ...dc  fever.  Of  sixty-seven  cases  of  the  pr  mary 
form  the  reports  of  which  i  have  gone  over,  in  only  nineteen  was  the  1',  y 
mention  made  of  acute  rheumatism  or  of  previous  rheumatic  attacks.    It  may  be 


1)1 


I  think,  safely  stated  that  ulcerative  endocarditis  does  not  occur  frequently  in 
rheumatic  fever. 

(b.)  rni'itmonia. — A  very  considerable  number  of  cases  are  associated  with  this 
disease.  Tluis,  in  seven  of  the  twelve  cases  which  have  fallen  under  my  notice 
this  obtains,  and  in  twenty-four  of  the  sixty-seven  cases  which  I  have  analysed. 
As  this  relationship  has  not,  so  far  as  I  know,  been  specially  noticed  by  any  other 
writer,  I  append  condensed  reports  of  these  cases. 

I.— Mary  D.,  aged  twenty-nine,  admitted  October  22nd,  1878,  in  an  uncon- 
scious state.  No  history  of  onset  of  attack.  Dulness  and  blowing  breathing  at 
right  apex;  systolic  murmur  at  left  nipple.  Temperature  range  from  104^  to 
107°.    Death  on  the  fifth  day  in  hospital. 

ylitfoywy.— Ulcerative  endocarditis  of  anterior  segment  of  mitral ;  red  hepatisa- 
tion  of  upper  half  of  right  lung ;  purulent  meningitis ;  infarcts  in  spleen,  which 
was  enlarged. 

II.— James  B.,  aged  thirty-eight,  a  healthy  man,  admitted  January  1st,  1880. 
Had  pneumonia  ten  years  before.  On  evening  of  4th,  got  feverish,  had  pain  iji 
the  side  and  cough.  On  admission  all  the  signs  of  consolidation  of  right  lun"' 
lower  three-fourths.  During  first  week  in  hosj)ital  delirium  set  in  with  prostra- 
tion. Patient  lived  for  forty-two  days,  during  which  time  he  was  in  a  low  typhoid 
state,  had  chills,  profuse  sweats,  and  a  parotid  abscess.  The  temperature  ran^e 
was  from  100-  to  104'.  After  the  second  week  the  lung  symptoms  subsided 
though  the  dulness  never  quite  disappeared. 

J Mtojtwy.— Extensive  ulcerative  vegetations  on  mitral  segments;  tissue  of 
right  lung  firmer  than  that  of  the  left,  but  not  granular ;  infarcts  in  spleen,  which 
was  enlarged. 

III.— M.  W.,  aged  forty-three,  a  well-built  man,  the  subject  of  syphilis,  admitted 
February  26th,  1880.    In  October,  1879,  he  had  had  a  severe  attack  of  inflamma- 
tion of  the  right  lung.     On  February  23rd,  had  a  severe  rigor,  followed  by  fever, 
pain  in  left  side  and  cough,  and  examination  showed  signs  of  pneumonia  of  lower 
half  of  left  lung.    Up  to  March  3rd,  patient,  though  delirious  at  times,  appeared 
to  be  doing  well.    Temperature  on  that  date  was  normal.     On  the  4th  he  had  a 
chill,  and  became  feverish  and  delirious.     From  this  time  until  his  death  on  the 
14th,  the  chief  symptoms  wore  prostration,  delirium,  occasional  chills,  and  pro- 
fuse diarrha;a.    Temperature  range  from  101°  to  104".    Lung  never  became  clear. 
Autoiisy.—^moW  vegetations  on  mitral  segments  ;  large  vegetations  in  right 
posterior  aortic  cusp,  with  destruction  of  tissue ;  base  of  left  lung  airless  a;id 
solid  ;  purulent  meningitis ;  spleen  large  ;  small  infarct  in  kidney. 

IV.— Eobert  L,  aged  twenty-nine,  admitted  June  4th,  1880,  with  a  history  of 
diarrho3f.  of  several  days'  duration,  chills,  fever,  and  cough.  Signs  of  consolida- 
tion at  left  base,  with  blowing  breathing.  He  was  known  to  have  aortic  valve 
disease,  and  there  was  a  double  murmur  at  the  base.  The  indammation  extended 
and  itivolved  n^sarly  the  entire  lung.  It  did  not  run  a  typical  course,  but  a  low 
typhoid  state  supervened,,  with  chilis  .ind  .sweats.  Temperature  range  from  yy= 
to  105°.    Death  on  July  1st. 

Autopsy.-0\i\  sclerotic  endocarditis  with  fusion  of  two  segments  of  aortic 
valves  ;  small  ulcerative  vegetations  ;  extensive  ulcerative  disease  of  aorta  with 
vegetations  and  four  aneurisms ;  lower  lobe  of  left  lung  showed  signs  of  a  re- 
sc.lving  pneumonia ;  infarcts  in  spleen  and  kidneys;  superficial  meningeal 
hajmorrhages.  ° 

V.-M.  G.,  a  young  girl  aged  nineteen,  jumped  during  a  fire  from  a  three- 


I 

1 


5 

story  window,  and  sustained  a  fracture  of  both  legs  and  of  the  lumbar  vertebra 
fehe  did  very  well  for  a  weei<,  when  the  temperature  rose,  and  she  had  cou-h 
sliortness  of  breatli,  and  pain  about  the  heart.  Delirium  came  on  with  prostra- 
tion, and  deatli  occurred  on  the  sixteenth  day  after  admission. 

yl«Av«//.-No  suppuration  about  the  fractures,  which  appeared  to  be  doinjr 
very  well;  a  large  endocardial  outgrowth,  with  destruction  of  substance  on 
anterior  curtain  of  mitral  valve  ;  hepatisation  of  central  portion  of  right  lun^  • 
infarcts  in  spleen  and  kidneys  ;  patches  of  membranous  (diphtheritic)  colitis  •' 
purulent  meningitis.  /  lo , 

VI-Edward  B.,  aged  sixty-three,  admitted  to  surgical  wards  March  31st  1881 
vvith  carlx.ncles  on  buttocks.  They  were  freely  lanced,  and  though  he  was  much 
debilitat^ed  and  had  an  irregular  temperature,  he  improved  considerably,  and  on 
April  2.th  the  wounds  were  doing  nicely,  and  the  temperature  was  normal, 
xhcn  signs  of  inilammation  of  left  lung  were  detected  ;  temperature  rose,  and 
there  were  rapid  breathing,  cough,  and  rusty  expectoration.  The  whole  or-an 
became  involved,  and  the  patient  became  greatly  prostrated.     Death  on  May  8th 

Aatops>/.-]iody  wasted  ;  bed-sore  on  sacrum  ;  carbuncles  had  almost  healed  • 
grey  hepatisa  ion  o  three-fourths  of  left  lung  ;  ulcerative  and  suppurative 
erdocarditis  of  op  of  one  of  divisions  of  anterior  papillary  muscle  with  exudation 
in  contiguous  chordai  tendineaj ;  numerous  infarcts  in  the  kidneys. 

Af  ^JJir*!  uof  "■;  ""^""^  ^"'*^'  '^'■^y'"'"^'  large  and  powerfully  built.    Admitted 

May  1.  th,  1881  with  pneumonia.    Had  had  two  previous  attacks  of  inflammation 

of  the  lungs     Rigor  on  the  11th,  followed  by  fever,  cough,  and  pain  in  right  side.  M 

When  admitted,  consolidation  of  lower  two-thirds  of  right  lung  was  determined.  ^'-' ' 

Delirium  set  in  early,    llesolution  did  not  supervene  and  the  fever  did  not  abate 

at  the  usual  time.    Patient  fell  into  a  low  typhoid  state,  with  delirium  and  free 

diarruva.    Temperature  range  from  102=  to  105°.    Petechias  appeared  in  the  skin. 

Doatli  on  the  thirtieth  day.     There  was  no  heart  murmur. 

A Hf ops>/.-Extcnsivo  ulcerative  endocarditis  of  mitral  segments  and  of  two 
of  aortic  cusps  ;  lower  top  of  right  lung  airless,  heavy,  linn,  and  on  section 
granular;  spleen  large;  infarcts  in  kidneys;  numerous  infarcts  in  intestines: 
purulent  meningitis. 

Of  those  seven  cases,  in  five  the  endocarditis  came  on  during  the  course  of 

smiple  pneumonia.     Cases  V.  and  VI.  were  complicated  by  surgical  disease.     In 

the  girl  with  fractured  legs  the  endocardial  j  uschief  appeared  to  develop  with 

the  inilammation  of  the  lung,  and  not  to  be  secondary  to  the  fractures     The 

patient  with  carbuncles  was  much  debilitated  and  succumbed  to  an  extensive 

pneumonia,      \\hethei   the  endocarditis  Avas  present  before  the  onset  of  the 

pneumonia  remains  doubtful,  but  I  think  it  scarcely  could  have  been,  as  the 

general  condition  of  the  man  was  improving  before  it  came  on.    The  association 

of  tliese  conditions  in  .such  a  large  proportion  of  cases  is  very  striking,  but  the 

relationship  between  the  processes  is  not  easy  to  trace.    Po  fjir  as  nno  may  iud"e 

the  pneumonia  in  the  above  cases  was  the  primary  morbid  change.     In  all  it  w"as 

of  tno  ordinary  lobar  variety.     Cases  of  ulcerative  endocarditis  of  the  right  heart 

have  been  described,  with  extensive  secondary  changes  in  the  lungs,  but  in  none 

ot  my  cases  was  the  pulmonary  process  of  a  pya^mic  character.    I  have  not 

specially  stated  it  in  the  condensed  reports  of  the  cases,  but  it  is  worthy  of  remark 

that  all  the  patients  were  either  debilitated  at  the  time  of  the  attack,  or  were  hard 

drinkers.    Many  constitutional  affections  predispose  to  endocardial  iiiHammation,  .  s  . , 

notably  rheumatism,  less  frequently  some  of  the  exanthems,  and  to  these  we  may 


J   1 


I 

4| 


1 

ill 


now  add  pneumon.a,  wj>.cl>  is  regarded  by  many  as  a  constitutional  .liscase    Tin 
fortunately  ti.e  forn.  of  endocardnis  winch  accon.panies  it  appears  to  b   nTore  ofVcn 
of  a  serious  nature,  judging  at  least  from  the  evidence  bel'ore  us.    With  onr 
sent  knowledge,  the  most,  I  think,  that  can  be  said  on  this  poTnUs  «i a  i n  "   f™" 
cases  of  inih.uiniation  of  the  lungs  there  is  a  tendency  to  T  rativ;      d'aTS' 
In  a  former  paper*  on  tlii.  subject  I  called  attention  to  the  fact  that  inSn, 
t.on  of  a  diphtheritic  character  had  been  observed  in  other  organs  nnn  1'    '" 
Particu  irly  in  the  colon,  in  which  region  Dr.  I3ristowe  met  withdi",  Ld  L  ^"^^^^^^^ 
turn  m  four  out  of  sixteen  cases.    There  was  purulent  nieningitl  i^^ fou/of  til' 
seven  cases  above  reported,  which  was  doubtless  secondary  to  the  endocTrditl 

(r.)  A  very  considerable  number  of  all  the  cases  of  ulce  ativrendo  fr^^V 
occur  in  connection  with  local  inflammatory  processes  of  an  rheaTthy  te  f 
this  group  the  cudocardiik  puerpemli,  of  Virchow  is  mo.t  rm,!,  ^^  ^'] 
not  unfrequently  complicates  the  endo-  and  periletri  irLrr  Tn''  "'"^ 
l-arturition.  It  is  further  met  with  in  acute  ^ZTotl^^^J^T^ 
gonorrha.a,  and  m  pya>mic  states.  In  some  cases  it  is  very  difficSt  to  srwh  fl 
lie  pya.mia  has  excited  the  endocarditis,  or  whether  the  for^r  has  C   1 

cjefonnity  ;  \.,  the  sanii':^:h:n^n  bli^^^^^^^^^^^  Z^^^^.  ^-t 

deformed  valves  with  recent  ulcerative  changes  de^  S  of  ^'^  T'^  ""'^ 
aneurisms  Probably  the  great  majority  f£^l^^;:r^f^ 
occur  m  this  connection.    These  cases  7,.„nllv  „  i  ^^^^^^.^^  «"  t^e  valves 

heart  disease,  with  little  or  no  f  e  ^fae?  ^, J  X  s  "  "f  1^'"  T"^^^^^  «^ 
symptoms  so  striking  in  other  instances     1^^.  '  ^F^'""'"^  ''  P^^'"^^ 

i-egular  fever,  or  sijns  of  ex  te  ive  embol  sm  ^^^^^  '''' r'  ^'"'  '''''  «^'«^*' 

the  process  going  on  but  the  clin  cal  p S ^^^  "-."^^-^  ^i 

form.     It  has  long  been  recorrnised  that  ,  Wm  ,  '  ^"'""'"y  infectious 

proneness  on  damaged  valves  to  o  tt  .       '  f    '"""''  '''''''''  ^'^^^^  '^'^^^^ 

plication,  the  valves  wer    ll  e  sub   c   of  t  .  r      P"f  ™oma  with  this  com- 

of  the  segments  ^^^l^^:^  ^      '^"^t^  "l^^ 
disease,  with  extensive  ulcent°ons  n,  d  11     •  '"'^^"^'^^  ^^  chronic  heart 

segments  was  met  with,      n     f^^^^^^  ^"  T'  ^°"^'*^°"  «^  ^^'^ 

blood  supply  may  as  Virchow  ~T  T  f   '  ''"'^  conse(juent  defective 

in  sclerotic  va^vel'to  ulerl^^^^^^^^^^^         '"^  ^^""^^"'^  *^  '^  -^^^  this  tendency 

a  predisposing  cause.  ^^^cordmg  to  Lancereaux  t  chronic  malaria  is  also 

theS^c  i:^ttt^:^Xru'']  '''-'  Y'''  '-'''  ^  ^-  P"^-  in 
conhned  to  the  left  side.  tC^^:^^':^'''^'''  ^^^^^*'""  '«  valvular  and 
remarkable  variety  prevails.    Th'r  1  ay  be       V's'    '  r"  "IT'  "'"^"'■"''  ^^^  ^ 

•  Archives  of  MaUcinc,  Fob.  1881,  New  York, 
t  Air/itixs  (niu-rala,  1873. 


much  ex 

has  beei 

pyiumia. 

post-mor 

twelve  cc 

was  also 

is  natura 

the  rapid 

to,  the  ill 

being  frc 

tlio    term 

The  expn 

vlcerenne,' 

affected  v 

often  fissi 

a  thin  fit 

On  sectioi 

The  consi: 

are  intimi 

large,  is  u 

thickness 

two  instar 

tive  outgr( 

chronic  he 

more  acut 

and  they  a 

of  the  va 

suppurati\ 

formed,  ai 

cases  occui 

with  pus  ; 

vegetation 

In  my 

vegetation! 

in  all  the  c 

in  a  specin 

definite  spl 

enclosed  in 

similar  ap| 

some  write: 

In  this  ( 

tions  of  the 

growths  of 

to  point  ou1 

plastic  vege 

The  rela 

Virchow,  El 

elements  wl 

stand  in  the 


fliscaso.  Un- 
30  more  often 
Vith  our  pro- 
liat  in  certain 
inclocai  -litis. 
It  inflanima- 

pneumonia, 
critic  exuda- 

four  of  the 
ocarditis. 
endocarditis 
y  type.    In 
cuous,  and 
3  following 
:sioiially  in 
ay  whether 
3  not  been 
his  form  is 
?,  in  most 
ons,  which 

!ry  diverse 
vith  great 
irotic  and 
:1  valvular 
lie  valves 
imples  of 
r  pyteniic 
en  slight, 
nature  of 
nfectious 
h  special 
!iis  com- 
'lich  two 
ic  heart 
I  of  the 
efective 
indency 

ition  of 
I  is  also 

>ints  in 
lar  and 
,  but  a 
stance, 
ithout 


mtich  exudation  nothing  deserving  of  the  name  of  a  vegetation.  My  evnerienco 
has  been  tliat  tins  variety  is  most  common  in  the  puerperal  sLT  nn d  7n 
py.^m,a.  Son.etimes  it  is  diiHcult  to  n,ake  out  the  erL"  r.  ti eul:,;"^,  " 
pos  -mortem  stannng  of  the  membrane  has  taken  place.  In  only  one  of  he 
twelve  cases  of  the  primary  form  was  the  lesion  of  this  nature  ancf  in  this  tho  o 
was  also  a  good  deal  of  swelbng  and  infiltration  about  the  bse  7Z  Ir  t 
IS  natural  to  suppose  that  lesions  of  this  kind  would  prove  more  an"  rous  by 
he   apjd  u,fcction  of  the  blood  with  sn.ail  emboli ;  and  in  the  case    u  frefe  red 

mg  free.  2.)  For  he  great  majority  of  the  cases  of  t  ,e  prinmJy  E 
t  e  term  "ulcerative"  hanlly  expresses  the  precise  anatomica  3  tTo^' 
Ihe  expression  used  by  French  writers  is  more  correct,  " /V,./:  "^v  " "^n  ^ 

i:T  "  ''°  '"^".^""^  ^'''"^  substance  and  vegetative  outgrowth  '  To 
affected  valve  presents  irregular  nodular  excrescences  of  a  greyishldSe  colour 
often  fissured,  cauldlowerlike  ;  the  surface  either  quite  smooth  an  1    overedt^^^^^ 

OnZ\        :r  ^""^  °''^"""''"  ^™"^  '^^P°™r''  «f  the  texture  o    the  n^  s 

n  sectum  the  cut  surface  may  be  uniform  and  fleshy,  or  bnlzen  and  g  an    a  ' 

Ihe  consistence  is  not  very  great,  the  masses  crnmblin,  on  firm  pressiire     Thev 

are  intimately  united  with  the  tissue  of  the  valve,  w  uch,  if  tl     Zet'ation  ^s 

arge  is  usually  indistinguishable  at  the  site  of  attachment  ;  indeed  fh;  whole 

thickness  of  a  segment  may  be  involved  and  the  mass  spring  from  both  sWes     In 

two  nistances  the  vegetations  were  of  a  fleshy  character,  not  friable     Trulcera 

t  ve  outgrowths  which  develop  on  the  sclerotic  valves  ^f  patients  the  subi  c   of 

chronic  heart  disease,  resemble  closely  in  coarse  features  fhose  met  wit  lin  tl^ 

niore  acute  process^    Small  calcareous  concretions  are  not  nncommrn  n  them 

o  1 1%^^^^^^^^  ''S  T  '"'"  n"''  -^<^om,ani.a  by  perforations  and  aneurS 
ot  tlio  valves.  (3.)  In  a  small  group  of  cases  the  endocardial  process  is 
nppurative  and  the  tissue  is  bathed  with  pus  corpuscles.  An  Xess  mav  be 
formed,  and  after  discharging,  leave  an  ulcer.  In  Case  VI.  o  the  g  "un  of 
cases  occurring  in  pneumonia,  the  tip  of  one  chorda  tendinea  was  soft  and  ba.ed 
^vlth  pus  ;  m  am.ther  case  there  was  a  purulent  deposit  at  the  base  of  a  la  4 
vegetation  in  a  sinus  of  Valsalva.  " 

In  my  previous  paper  I  have  dealt  with  the  histolocrical  characters  of  fb« 
vegeations,  and  would  here  simply  state  that  the  microcC  1  rbe  "pr  s  nt 
n  all  the  cases  examined  by  me.  A  peculiar  arrangement  of  the  n  was  led 
n  a   pocmen  obtained  from  a  cow    In  addition  to  the  usual  forms  the  e  were 

ncCt:™ie:  *"/:"""  -^-^'^-^king  like  aggregations  of  micrococ 
enclosed  m  capsules.*    In  two  specimens  from  man  I  have  met  with  somewhat 

r^'wrS"^""^- ' "'-'  ""^  ^^^" '''  ^-'^'"^^  ^^^--^«  ^-^Tdt; 

In  this  connection  I  may  state  that  micrococci  are  not  peculiar  to  the  ve-^eta- 
tions  of  the  ulcerative  form  of  endocarditis,  but  exist  in  the  small  boad^ike  ™t 
growths  oi  the  rheumatic  and  other  varieties  of  the  disease,  as  Kbs  was   li    fi'st 
to  point  out     My  experience  tallies  with  his  ;  in  seven  spedmens  of  veTrnos    o 
plastic  vegetations  which  I  have  examined,  all  contained  micrococci. 

ihe  relation  of  rhe  micrococci  to  the  disease  has  been  very  fully  discussed  bv 
Virchow,  Lber  h,  Klebs,  and  others,  most  of  whom  hold  that  fhey  arcthe  specific 
eements  which  account  for  the  peculiar  malignancy  of  the  disease'^id  thaftht 
stand  in  the  same  portion  in  this  affection  as  the_baccillus  in  anthrax     There 


8 

arc  some  points  wl.ich  should,  I  tliink,  make  us  hesitate  to  accept  tJ.is  view  with 
out  further  evidence.    .Micrococci  abound  in  all  forn.s  of  endocardial  vegeTaMot 
-m  the  warty  outgrowths  of  rheumatic  endocarditis,  in  the  vegetati^)  fs  „f  "  d 
clerofc  valves,  as  well  as  in  the  excrescences  which  develop  in  the  Tcu?o '^I- 
t.ve  form     This  latter  is  a  malady  which  runs  the  course  o'f    n  ilXe  dtl 
and  may  destroy  life  in  four  or  five  days.    The  micrococci  are  sunnos  ^to  1  n 
access  to  U>e  blood  and  to  excite  in  some  way  endocarditis ;  at  Z  ra  "  tT  ^ 
flounslnn  the  vegetations  which  are  regarded  as  centres  for  the  dltribut  or  of  l7 
germs  throughout  the  body.     In  the  majority  of  cases  en.boli  are    ar  ied  It 
f  om  the  vegetations  and  infarcts  produced  in  the  different  or4n       1     otlnr 
casas,  equally  malignant,  the  vegetations  may  remain  unbroke^a^,^' no  cm  n1 

:Sst  r  he  b^  tr  ^r '"  ^  ™^  °'^^^^"^^^"" «---  ^i^e  mi:;  1  i  r ,« 

exist  in  the  blood  during  the  course  of  the  nvilnrlv      v^..         xi 
found  in  the  infarcts.    The  occurrence  of  mLoe tf  in  ^he  Zltl7  7T''''. 
rheumatic  endocarditis  and  in  the  extensive  ulceS  out^rt  '   LT     h"'  "^ 
with  in  old  sclerotic  valves  are  facts  strongly  op^oled  to  t  le  vt^^ 
poisonous  nature.    The  micrococci  annpnr  L  hlT  I  T        *^"'""  ^P'^^^^'^ 

Klebs  states  that  those  of  rCZ^'^SL^^.  X^^!  ITa^r-f 
tint.  I  cannot  say  that  these  differences  have  been  constaT  nT  ,  -^^ 
which  I  have  examined.  It  seems  a  pertinent  wuestlnto.sk  if  /  '^'T'''''' 
form  of  endocarditis,  the  micrococci  are  so  note  t  ^Vv  in  ot  "  '^'' "^''^'^^^ 
they  are  equally  prevalent,  should  they  be  inert  Of  con  rsP  f  T'  "'  7^'''^' 
the  micrococci  may  be  of  diflerent  kindVnrnn  "\'^"''®  '^  "^^V  be  urged  that 
resistance  offered  by  the  tissues  ?o  thr'n^rr ''''''■''  ^"'''''^^'  ''  '^^'  '^'^ 
that  it  is  only  in  we^  ned  and  Ml,    h    P'"f 'f^^^T  ^'^"^«  ^"  ^Jifferont  cases,  or 

There  is,  I  tlfink,  ^i^^t^^rZ^lX  fT  '"'^  ""''''''  ^^-- 
the  conditions  under  which  end  di  is  fefeZ^^^^^^^^  Tf  '''''r  "  ^'°  ^^^^^^ 
the  patients  are  the  subject  of  somfo  ht  constitrt  "1  r^'  '""""^^^^^  '^^' 
say,  predisposes  to  it.  What  de  erTines  tl  e  nri  f  "^  f  ?''"''  ''^''^'  ^«  ^° 
do  not  know,  but  the  soft  locSveSon^^^  the  endocarditis,  we 

development  of  micrococci.     They  IvLZThTJr      .  '"^^^'^'t  "^^"«  f«r  the 
ponents  of  endocardial  outgrowth'  aXf  br  n  fibriU  'r  .''  '""''^  "°™'^^  '^"'"- 

and  among  which  the  micrococci  abou-      I     s  e';^  e,:^^^^^^^^^^^  'r '''''' 

common  elements  in  .a  'iPrit^a  nt  ^..a       j-  i  '^^"''^"'^  "lat  these  structures  are 

'-i'y^moJZ:rL:z:'^z:^jzrH^^ '?'"'  '""""^  *""■ 

either  for  Iho  develonmcnt  of  tl,rn      ,'!  *" '"r  H'cy  »ro  responsible 

w«,  ™  .he  ,ra™  for  ^j  lui:  tT;  *»:'  ^ 'nT^^rT'  """*'• 

yet  a  very  positive  opinion.  ^-vmence  does  not,  I  think,  warrant  as 


i 


I 


i 


is  view  with- 

1  vegetations 
tioiis  of  old 
icuto  ulcera- 
Jtivo  disease 
>scd  to  gain 
y  rate  they 
•ution  of  the 
irried  away 
la  other 
no  emboli 
occi  do  not 
constantly 
etations  of 
uentlymet 
eir  specific 
es,  though 
.  brownish 
specimens 
malignant 
!  in  which 
rgod  that 
r  that  the 
'  cases,  or 
es  thrive, 
we  study 
ibly  that 
-h,  as  wo 
ditis,  we 
i  for  the 
(lal  com- 
eposited 
ures  are 
y  diflfer- 
lonsible 
iracters 
■rant  as 


'§ 


h 

J, 
\^    > 


ki"  <  ! 

fill 


I 


X  l.Y 


vnnw  TMK 


"Canada  Medical  &  Surgical  Journal,"  Montreal. 

Fbbiiuary,  1882. 


• 


» 


ON  THE  BRAINS  OF  CRIMINALS. 


WITH  A  DESCRIPTION  OF  TIIR  liRAIXS 

(PlATFS  I.   ANt)  II.) 


op  TWO  MURDERERS. 


Bv  WILLIAM  OSLEIl,  M.D..  M.R.C.R,  Lond 
Pressor  Of  the  In.i.Ues  of  Medicine  i„  McOiU  Unive.it,.  and  P.,.eian 
10  llie  Montr..'al  yuneral  Hospital. 


[Hewi  h'-/'i 


«.  .V;ii,„-n:„„,;.„,  ,v.,„,.„„  ,„  .„,„„„„,, 


Menially  „,1  bod.ly,  we  are  largely  the  result  of  an  here- 
<l.tary  orga„«t,o„,  and  the   environment  in  whieh  we  I  ave 
been  reared.    The  ehild  of  a  bushman  nurtured  in  thlfami  y 
of  a  philosopher  will  not  be  able,  „ith  favourable  surrou„dr!s 
to  nse  aueh  above  hi.,  race  level ;  the  ohild  of  a  nhilosoZ  ' 
•e  red  among  the  bushmen.  will  not  reaeh  his  paternal  stand  rd 
but  the  gro.,3uess  of  the  savage  natures  around  him  „■  lUave' 
-.g     to  pull  h,m  down,  and  what  is  fine  will  learu  to  sym  a  M 
w.h  teehay.     In  the  former  case,  the  individual  eaijttan- 
seend  Ins  organization;  and  in  the  latter,  he  cannot  burs   the 
.ron  bars  of  h,3  environment.  That  the  mental  and  moral    ata 
0  a  man  ,s  determined  by  the  conformation  and  development  „ 

ihe  col'  ""  t"™  ""'  ""^  '*°'  °f  physiological  psychoToSl 
The  conformation  is  a  matter  of  inheritance  ;  the  developmen 
of  edueation  (in  its  widest  sense).  The  different  menta  cTd  ! 
tions  of  individuals  are  the  expression  of  subtle  differen  e"  in 
cerebral  structure,  j„,t  as  the  diversity  in  the  features  of  me„ 
.3  the  result  of  mmute  variations  in  the  arrangement  of  thelue 


*>n 


1 


i' 


'■■■.  ,'; 


V     u 

1 1  t 


li^ 


of  till  face.  That  a  faulty  physical  basis  can  have  no  other 
soqupnco  >}nu  a  faulty  montal  am)  moral  constitution  is  acknow- 
le(l;,'t'(l  and  actcl  uj*  '\v  every  one,  ho  far  as  idiots  and  iinl)ociles 
are  concerned,  hut  that  mental  and  moral  oI)li(|uity  is  invariably 
tho  outcome  of  an  ill-conforracd  or  ill-developed  brain  is  a  doc- 
trine novel  and  startlin;,',  tliou;^!!  lo^^ical  enou;,'Ii  from  the  stand- 
point of  modern  physical  fatalism.  Kndcavoiirs  have  recently 
been  made  to  jnit  this  theory  on  firm  grounds  by  showing  that 
in  a  lar<^c  number  of  criminals  tho  type  of  brain  dillers  from  that 
in  the  law-abiding  members  of  the  community. 

Anatomists  and  j)hysiologists  have  of  late  paid  much  attention 
to  the  conformation  of  the  brain  surface,  and  the  convolutions 
and  fissures  are  now  studied  with  care  and  minuteness.     In  a 
typical  European  brain,  the  cerebellum  is  completely  covered  by 
the  cerebrum,  and  the  general  arrangement  of  the  g'"ri  and  sulci 
is  such  that  there  is  rarely  any  difliculty  in  mapping  them  out 
and  assigning  their  proper  names  to  each.  Thus  on  the  external 
surface  of  each  hemisphere  we  recognize  two  fissures  which  are 
constant  and  invariable  ji  position — the  fissures  of  Sylvius  and 
of  Rolando,  (^central  sulcus.)  Other  fissures  constantly  present, 
but  less  definite  in  their  arrangement,  are  :   the  inter-parietal^ 
which  passes  through  the  parietal   lobe,  tho  parieto-occipital ; 
separating  tho  parietal  and  occipital  lobes,  best  seen  from  the 
median  surface,  the  superior  (1st),  inferior  (2nd),  and  ascend- 
ing (3rd)  frontal  sulci  and  the  \st  and  2«c?  temporal. 

On  the  median  surface,  the  calloso-marginal,  the  parietal- 
occipital,  the  calcarine  and  collateral  are  well  marked  and 
distinctive. 

The  convolutions  or  gyri  separated  by  these  fisKures  are  re- 
markably uniform,  and,  though  often  inters.otod  by  t;«ii  sidiary 
sulci,  can  usually  be  determined  without  ditficuity.  Of  these, 
the  only  ones  which  need  be  now  mentioned  are  the  three  frontal, 
1st,  2nd  and  3rd,  tho  general  direction  of  which  is  parallel  to 
the  longitudinal  fissure  and  the  two  central  gyri  which  bound  the 
*^am:?  of  Rolando  on  either  side. 

Ir,  tae  typical  brain  the  main  fissures  are  unconnected  with 
iii^'ii  other ;  ti  -.'s  the  fissure  of  Kolando  is  isolated  and  does  not 


unite  with  the  Sylviuf.  lissurc  I.elow,  or  tho  aseciuVuv^  fn„.tnl  or 
asooM.hn^r  parietal  sulci  o„  either  -wle.  The  Sylvian  fissure  does 
not  join  with  any  of  the-  suU;i  ahove  or  helow  it. 

Prof  IJene.likt  of  Vienna  has  ma.lo   a  special  stu.ly  of  the 
brains  of  cruninals,*  an.!  believes  that  he  has  met  with  peeuli  .ri- 
.es  suffic.entlymarked  to  warrant  tho  following  proposition  : 
•  The  Lrain,  ot  annilnah  rMbit  a  deviation  from  the  normal 
type,  and  cnmtnals  are  to  be  viewed  a»  an  anfhropolomraf 
variety  oj  their  .pedes,  at  least  aounujst  the   enltured  raees  " 
Ihe  two  pocuharities  on  which  he  lays  stress  are  (1st)  tho  con- 
fluonce  of  many  of  the  primary  fissures  and  (2nd)  tho  existence 
of  four  horizontal  frontal  ;,7ri.     He  proposes  to  establish  a  eo,^ 
fluent  fissure  type  of  brain,  and  he  illustrat(.s  its  most  im,,  rtant 
characteristic  by  saying,  "  that  if  we  imagine  the  fissures  ^o  be 
water-courses  it  might  be  said  that  a  body  fioating  in  any  one 
ot  them  could  enter  almost  all  tho  others."     This,  of  cou  se 
means  the  absence  of  numerous  bridges  of  nerve  matter  winch 
normally  separate  the  fissures-defects,  marking  an  inferior  de- 
velopment  of  the  brain.     J3etween  the  normal  type  with  isolate  I 
fissures  and  the  type  with  confluent  fissures  there  will  naturally 
be   ransitions,  but  he  calls  attention  to  the  number  and  variety 
of  the  connections  in  his  series  of  the  brains  of  22  criminals  as 
supportmg  the  truth  of  his  proposition.  He  states  that  the  brains 
of  individuals  in  the  lower  grades  of  society  approach  nearer  to 
the  -nd  type,  and  it  is  probable,  though,  as  yet,  full  data  are 
wanting,  that  the  brains  of  the  inferior  races  of  men  also  conf.rm 
more  closely  to  this  than  to  the  type  with  isolated  fissures.     Let 
us  see  now  how  far  he  has  been  able  to  establish  the  truth  of  this 
view.     Of  38  hemispheres  from  the  22  criminals  tho  following 
were  some  of  the  most  interesting  points  :—  " 

I.  The  >8Mre  0/ i^o/anio  communicated  with  ; 

(a)  jis.  Syl.  completely  in  18,  incompletely  in  G. 
(i)  with   ^rd  or   ascendiny  frontal,  complete  in  11, 
incomplete  in  2, 

*   On  tile  Rruitiu  of  fV-minnlt!     Vt^  1-^-        Tn  "  ^ 

(Woo<l  &  Co    V  ;;  York    ra«   '  ^''-■""%^f'^''-    Tr.iu«Iutfd  by  Dr.  KmWer. 
Vo.40,  1880. '  -^^^^   ^""^'   '381-      Gent.  f.d.  med.  ^Vt^^en^cha/ten,    187«,  a«d 


I 


6 


III. 


(c)  with  the  1st  or  superior  frontal  sulcus^  complete 

in  9,  incomplete  in  1. 
((i)  with  inter-parietalis,  complete  in  7,  incomplete  in  4. 

Of  the  19  brains  there  was  not  one  in  which  the  fissure  of  Ro- 
lando had  not  on  one  side  a  connection  with  some  other  fissure. 
Altogether  there  were  58  connections,  35  on  the  left  and  23  on 
the  right  side. 

II.  T[\Q  Sylvian  fissure  cormamuc^te^  mih. : 

(rt)/s.  jR.  in  18  completely,  in  6  incompletely. 
(5)  yiVlx  frontal  sulci  in  18,  incomplete  in  7. 
In  7  brains  it  existed  on  both  sides  ;  only  absent  on  both  sides 
in  3. 

(c)  with  fis.  inter-parietalis  in  22,  incomplete  in  (J. 

(d)  with  1st  temporal  in  18,  incompletely  in  4. 
The  fis.  inter-parietalis  communicated  with  : 

(a)  fis.  R.  complete  in  7,  incomplete  4. 

(b)  fis.  Sylv.  complete  22,  incomplete  7. 

(c)  1st  T.  complete  19,  incomplete  G. 

In  the  38  hemispheres  there  were  51  complete  and  lij  shallow 
connections  of  the  inter-parietalis. 
The  soissura  hippocampi  communicated  with  : 
parieto-occipital,  complete  17,  incomplete  2. 
V.  The  calloso-marginal  fissure  : 

with  parieto-occipital,  complete  8. 
VI.  The  parieto-occipital  : 

with  inter-parietalis  and  horizonal  occipital,  complete  21-, 
incomplete  0. 

These  were  the  most  important  connections  ;  the  others  I  shall 
not  refer  to. 

The  second  peculiarity  which  Pi'of.  Benedikt  has  noted  in  the 
brains  of  criminals  is  the  existence  of  4  horizontal  gyri  springing 
from  the  ascending  frontal  or  anterior  central  convolution.  This 
he  regards  as  an  animal  similarity,  and  a  reversion,  so  to  speak, 
to  the  typical  four  primitive  gyri  of  the  brains  of  carnivora.  The' 
fl)urth  gyrus  is  formed  by  the  splitting,  by  a  deep  fissure,  of 
either  the  1st  or  2nd  convolution.     In  his  latest  communication 


IV. 


7 

on  this  point/  the  results  are  given  of  the  examination  of  87 
hemispheres  (from  44  criminals),  of  which  only  42  presented  the 
normal  type  of  frontal  convolutions,  and  27  showed  four  gyri. 
In  these  the  additional  gyrus  resulted  in  8  from  the  splitting  of 
the  superior  ;  in  10  from  the  division  of  the  middle  convolutron. 
In  1-3  there  was  an  imperfect  division  into  four  gyri.  In  two 
hemispheres  there  were  five  frontal  convolutions. 

Through  the  courtesy  of  Dr.  Desmarteaa,  Jail  Surgeon,  I  was 
present  at  the  autopsy,  and  secured  the  brain  of  the  man  Hay- 
vern  who  was  executed  for  the  murder  of  a  fellow-convict ;  and 
the  Department  of  Justice  permitted  me  to  secure  the  brain  of 
Moreau,  who  was  executed  at  Rimouski. 

I.— Hay  vern,  aged  28,  was  a  medium-sized  man,  of  no  trade  ; 
Irish  descent ;  parents  living,  and  respectable  ;  no  insanity, 
mebriety  or  neurotic  disease  in  the  family.  He  had  been  a  hard 
dnnker,  and  as  a  child  was  stated  to  have  had  fits.  There  is  no 
evidence  of  the  recurrence  of  these  in  adult  life.  He  was  serving 
a  term  in  the  Penitentiary,  havnig  been  sentenced  for  highway 
robbery  in  1879.  He  had  previously  been  in  jail  more  than 
twenty  times,  and  may  be  taken  as  a  good  representative  of  the 
criminal  class.  The  details  of  the  murder  show  deliberation,  and 
there  was  no  evidence  to  show  that  the  act  was  performed  dur- 
ing a  paroxysm  of  epileptic  mania. 

The  skull  was  somewhat  ovoid  in  shape,  dolicho-cephalic  ;  the 
forehead  rather  low  and  retreating.  The  calvaria  was  of  moderate 
thickness  ;  no  signs  of  injury,  old  or  recent. 

Brain,  la><t  oryan  examined.  PI.  /.—Vessels  were  empty; 
drained  of  blood  by  the  opening  of  the  vessels  of  the  neck,  both  in 
front  and  behind.  Membranes  were  normal.  Weight  of  organ, 
1320  grammes  (40j  ozs.)  Cerebellum  completely°covered°  by 
cerebrum.  I  obtained  the  left  hemisphere  for  special  study,  and 
the  details  of  its  structure  are  as  follows  :— 

Anturo-postorior  diiiniftur ir  r,  ,„>. 

((iniispliLTic  arch .,^  g  „ 

Anterior  curve  (tip  of  Fr.  lolio  to  Fi's!  Roi  ).' u'  » 

Midille  curve  (from  Fis.  Uol.  to  Par.-ocrip    Fi.s  )    '  *  "   G  ''  " 

Posterior  curve  (from  Par.-oc.  to  tip  of  Oceip.  lobe')' '.'.   <^'.l  .. 

*  Centmlb./J.  med.  t\'isseiiiic/t/l.,  No.  40,  1880. 


f  I 


8 

i^ylvianfismre  (Fii/.l'jy'm  addition  to  the  normal  asoendingand 
horlzonal  rami,  presents  a  radial  branch  which  passes  into  the 
frontal  yyri  (a),  a  short  radial  extension  into  the  asc. parietal  (b) 
and  a  shallow  communication  with  retro-central  sulcus  (o). 

The  fissure  of  Eolando  (F.R.)  or  central  sulcus  is  separated 
from  the  F.S.  by  a  very  narrow  bridge  of  brain  substance.  It 
has  no  other  connections. 

There  are  four  well-marked  frontal  gyri  [1,  2,  3  and  4]  ; 
the  extra  one  (2)  appears  to  be  formed  by  the  splitting  of  the' 
superior  or  1st  gyrus,  though  its  base,  where  it  joins  the  asc?. 
front,  gyrus,  is  in  the  position  of  the  middle  or  2nd.  fr.  gyr. 
As  can  be  seen  in  the  plate,  there  are  two  radial  sulci  which 
pass  from  a  point  just  behind  asc.  ramus  of/s.  Sylv.  and  ascend 
almost  to  the  loyig.  fis.  They  are  deep,  and  the  hinder  one  has 
a  crucial  extension  in  the  position  of  the  2ndfr.  sul. 

The  sulcus  inter-parietalis  presents  a  well-marked  radial  por- 
tion  which  passes  up  behind  the  ascending  parietal  convolution 
m  Its  whole  length  (asa.  pariet.  or  retro-central  sulcus)  ;  the 
sagittal  part  passes  back  into  the  parietal  lobe  and  divides  into 
two  branches,  one  of  which  (d)  curves  round  the  supra-marginal 
gyrus  and  unites  with  the  1st  temporal  fis. ;  the  other  (e)  ascends 
to  the  median  border,  and  is  continuous  with  a  sulcus  which  joins 
the  paneto-occipital. 

The  asc.  par.  gyrus  (retro-central)  is  well  developed,  as  are 
also  the  angularis  and  supra-marginal. 

The  horizonal  (or  sup.)  occipital  sulcus  is  well  developed  •- 
It  does  not  join  the  par.  occip.,  but  sends  branches  into  the^v' 
cmms.     It  appears  to  join  the  -Ind  temp,  sulcus,  but  the  brain 
as  lacerated  at  this  point,  and  it  is  difficult  to  make  out  th^ 
connection. 

The  l8(  temporal  mlcm  is  8»ngly  marked,  passes  up  and 
Jons  the  mter^arietal.  The  2,uj(  u.np.  ca„„  t  be  ,ve7n,ade 
out  on  account  of  the  laceration.  'veu  maae 

3tro„°J!;'d™t°  r*™  '■''^-  ■^'  "'*  """"-"""^•"O'  >ulcn>  is 
sttongly  developed,  presents  numerous  perpendicular  branches 
an     ermmates  by  two,  one  of  which  J)  ascends   „  t  e  „,,  ,' 
Posmon  belund  the  retro.«„,r.a  ,,„,.,  the  other  (^)  curves 


round  and  divides  the  oyrm  fornicatm  from  the  pre-ctmem  Cov 
Muadnlateral),cxtending  to  within  a  short  distance  of  the  calcarine 
fissure,  and  uniting  with  the.A's.  cmclata. 

The  gyrus  fornicatm,  in  the  anterior  half  of  its  extent,  pre- 
sents a  well-marked  sulcus  running  along  its  centre. 
Jheparieto-ocdpital  is  deep  and  well  marked  ;  it  has  a  branch 
(/O  which  curves  over  the  border  and  unites  with  the  inter- 
panetal.  The  calcarine  fissure  unites  with  thej.«r.  ocdp.,  and 
the  conjoined  sulcus  communicates  with  the  mssuraLpo- 
campi  by  a  wide  groove  (0. 

The  sulcm  collateralis ^mx,  the  calcarine  by  a  large  fissure  (  /), 
which  ends  just  at  the  handle  of  the  fork  oHhoparlcip.  and  i  - 
carvne.  Another  sulcus  (k)  passes  from  it  round  the  under  surface 
of  the  occipital  lobe,  dividing  the  temporal  cjyri  from  the  occipital 

Ihe  orbital  yyri  are  separated  from  the  frontal  anteriorly  by" 
a  well-marked  fissure  (fronto-marginal  of  Wernicke) 

The  convolutions  of  the  inmla,  normal. 

According  to  Benedikt's  views,  this  hemisphere  is  a-typical  in 
the  following  particulars;—  ^^ 

(a)  The  union  of  the  Sylvian  with  the  1st  frontal  sulcus. 

(d)  The  extension  of  the  calloso-maryinal  fissure  between  the 
gyrus  formcatus  and  the  pre-cuneus. 

5!?,  fj!^  ""'^^  ^f  *'^«  collateral  and  calcarin,  fissures. 

(/)  The  fission  of  the  1st  frontal  convolution  into  two  parts 
so  that  there  appear  to  be  four  frontal  gyri-a  condition  Ihich 
-Benedikt  lays  great  stress  upon  as  a  marked  a^iimal  similuritu 
in  the  human  brain. 


Jv  uT'  !.'™^"  ^'''"''  ^"  ^^'  ''''''^y  «f  Rimouski,  aged 
40,  French-Canadian,  murdered  his  wife  last  summer,  and  was 
executed  on  the  13th  of  January.  He  was  a  short,  vel-v  power! 
fully-built  man  uneducated,  and  of  a  morose  dispositi^i ;  was 
temperate,  and  had  never  before  been  convicted  of  any  crime 


■,t|    f    I'    r 


11     .' 


10 


He  had  not  lived  happily  with  his  wife,  and  quarrels  had  bgen 
"•eiiuent ;  one  day,  wheji  in  the  woods  together,  he  cut  lier  head 


fr 


open  with  an  axe.     The  deed  was  aj)parcntly  premeditated, 


It 


out 


idc 


that  ho  had 


as 
to 


came  oui  in  evuioncc  mat  no  liatl  ottered  money  to  a  man 
do  it  for  him.  After  the  act  and  during  the  trial  ho  maintained 
his  usual  stolidity,  and  did  not  appear  to  take  a  very  deep  interest 
in  the  proceedings.  Indeed,  it  is  stated  that  he  was  unaware, 
until  some  time  after  the  sentence,  that  he  was  to  be  han.red.' 
The  autopsy  was  performed,  about  an  hour  after  his  deatl^by 
Dr.  Jlelleau,  and  the  brain  was  secured  by  II.  V.  Ogden,  e!a. 
and  brought  to  mo  in  excellent  condition  for  examination. 

Organ  large,  weighed  about  1587  grms.  (5G  ozs).  [PI.  JJl 
The  hemispheres,  though  large,  did  not  completely  cover  the 
cerebellum.  Membi'anes  were  normal ;  vessels  of  the  pia  mater 
and  the  subjacent  grey  matter  dcei»ly  engorged. 

Left  hevmphere  {PL  11,  fiy.  ^).-Fk\lv.  \    separated 
from  ascendmg  parietal  by  a  very  narrow  and  groo\od  gyrus 
and  johis  the  inf.  front,  by  a  shallow  sulcus  {a).  °        ' 

Fis.  Rolando  sends  a  deep  fissure  (b)  across  the  upper  end  of 
asc.  par.  yyr.,  which  curves  round  the  margin  and  unites  with 
>•.  cruciaia  of  iV^ irre-mnem.    There  is  not  a  well-marked  a,c 
or  ^Td  front,  ml.     The  \,tfr.  ml.  lias  a  short  vertical  branch' 
and  only  extends  for  2.5  cm.  from  a.c.  front,  gyr.,  when  the  Ut 
and  2nd  convolutions  fuse,  but  beyond  this  it  is  again  apparent. 
^na  front,  sal.  has  a  short  vertical  branch,  and  joins  ihe  fis 
bylv  by  a  narrow  groove.  Its  anterior  extension  is  well  developed 
Ihe  Srd front,  yyr.  is  large  in  comparison  with  the  1st  and  2nd 
Ihe  «6Y?./mii;.  ^^r.  is  large. 

The  a,c.par.  ml.  (retro-central),  which  is  usually  united  with 
the  mter-panetal,  and  called  its  radial  portion,  is  isolated,  and 
only  joins  the  fis.  Sylv.  by  a  shallow  furrow  (c).     The  anc  \ar 
yyr.  IS  narrow.  '  ^ 

The  inter.pa.'ietal  fis.  runs  almost  parallel  to  the  asc.  par 
and  fis.  RoL,  being  separated  from  the  former  by  a  narrow 
convolution  which  joins  the  sup.  parietal  lobule.     Below  it  joins 


Qy 


I 


pan 


be  well  develuped. 


11 


"•o'irig  gyri 


Thfi  ls<  tenip.  sid.  is  crossed  in  two  i)laces  by  bi 
uniting  the  1st  and  2nd  convolutions.     Posteriorly  th°s  Tufcu's 
lias^  two  branches-one  which  joins  the  l.  par.,  the  otlier  the  inf. 
occip.     The  -Ind  temp.  snl.  is  not  well  marked. 

The  sup.  occip.  sul.  joins  the  par.  occlp. ;  the  inf.  occip.  sul. 


sup.  occip.,  sii\il 


the  1st  tonp 

On  median  surflice,  par.  occip.  fis.  unites  with  o.^ 
by  a  shallow  sulcus  with^A's-.  cruelata  o^ pre-cuneus. 
Calcarine fis.  normal;  caneus  small. 
Fis.  collateralis  long,  and  sends  numerous  fissures  into  qm-i 
Imguahs  and  fusiformis. 

Sul.  ccilloso-mary.  has  many  fissures  entering  the  1st  front 
9>jr.     Gyr.Mnicatus  is  fissured  longitudinally.      Orbital  ami 
normal ;  well  m'^xU,\  frontal  marginal  sul.  No  external  orbital 
tissure.     Insula  well  developed,  and  has  9  gyri. 

Right  hemisphere  {PL  U.^fuj.  4)._i7..  Sglv.  joins  ^rd  or 
^^^o.Jront.  sul.  (a),  and  the  asc.  par.  (b)  (retro-central)  by 
shallow  furrows  Fis.  Itol.  unites  with  1st  front,  (c)  and  asc. 
par.  Qd)  sulci  by  narrow  giooves. 

The  aso  front,  sul.  arises  by  a  shallow  fissure  from  the  fis. 
Sylv  anci  then  at  the  base  of  the  'Ind  front,  gyr.  joins  the  Ld 
front  sul.  l,t,  2nd  and  ^rd  frontal  ggri  are  well  developed 
and  distmct  posteriorly.  Anteriorly  they  .re  fused  and  crossed 
by  many  secondary  sulci.  Asc.  frontal  gyr.  is  very  narrow  in 
Its  centre. 

Inter.parietal  fis.  has  a  well  marked  radial  portion  (the  asc 
par.  or  retro-central).  The  sagittal  part  passes  back  and  presents 
three  divis.ons-one  (.)  enters  the  sup.  par.  lobule,  a  second  ( f) 
passes  directly  back  and  joins  a  fissure  in  the  position  of /»/ 
occip.,  which  reaches  to  the  tip  of  occip.  lobe,  and  the  third  (a) 
part  passes  vertically  down  and  unites  with  1st  temp,  sul  and 
has  a  branch  which  crosses  the  2nd  temp.  gyr. 

Asc.-par.  convolution  is  large  below,  narrow  above.     The 
ayigular,  mpra-niarginal  and  sup. par.  lobule  are  much  fissured 

1st  temp.  sul.  joins  i.-par.  ;  the  2nd  is  not  marked.     Several 


oblique  sulci  cross  tlu;  2nd  and  -3rd  teui 
jo'ma  par.  occip. 


p.  gyr.    Sup  occip.  sul. 


!  ; 


■ 

* 

!             I 

5, 

H-     ' 

12 

On  the  median  surface,  ixir.  occlp.  fin.  joins  sup.  oecip.  ;  the 
calcarine  enters  soimint  hippoccmpi  and  joins  tho  fis.  collateralis 
by  a  shallow  groove.     Fis.  collatemlis  large  and  deep. 

The  cuneHs  is  i,mall ;  pre-cimeus  (lob.  quad.)  is  large  and  its 
anterior  boundary  ill-defined. 

Calloso-marginal  fis.  extends  to  level  of  base  of  1st  frontal, 
and  then  curves  up  to  the  margin  of  the  hemisphere,  being  in- 
terrupted by  a  broad  annectant  uniting  the  gyr.  fornimt.  with 
1st  front.  Beyond  this  there  is  a  short  extension  which  joins  a 
complex  series  of  sulci  in  the  pre-cuneus. 

Orbital  gyri  normal.    There  is  a  narrow  fronto-marginal  sul 
There  is  a  well-marked  external  orbital  fissure. 
The  chief  points  to  be  noted  are  : — 

1.  The  absence  of  complete  coveringof  cerebellum  by  cerebrum 

2.  On  both  sides  the  pre  and  retro-central  fissures  were  sepa- 
rated from  >.  of  Sylvias  by  very  narrow  and  grooved  gyri. 

3  The  left  >..  liolando  joins  fis.  cruciata  oi  pre-cuneus,  and 
on  the  right  side  it  is  imperfectly  separated  from  1st  front,  and 
aso.  par.  sulci. 

4.  The  inter-parietal,  on  both  sides,  joins  the  1st  temp  sul 
and  on  the  right  side  is  much  more  developed  and  joins  the 

5.  On  the  median  surface  the  calcarine  on  the  right  side 
enters  the  scissura  hippocampi. 

There  remain  two  questions  for  consideration  :  first,  to  what 
extent  does  Professor  Eenedikt's  confluent  fissure  type  of  brain 

isTreliarr  "'^"'"^.'"^!^^^-  ^^  "-  community/and  how  far 
IS  ^reliable  as  an  indication  of  defective  development  ? 

With  a  view  of  ascertaining  how  far  the  confluent  fissure  type  of 
bum  exists  among  the  lower  classes  in  this  community,  I  have  ex 
ammed  carefully  68  hemispheres  from  U  individuals,^dl   Uho^ 
were  patients  in,  and  died  at,  the  General  Ilospit        M^tTf 

indVv;?        c  .  '°'"^  '^'"*^'"«  «^  '^l^^^^'^ter  of  any  of  the 

a^^o^tsor  t"  T'''''^  ^'''^^"^^' ^^^  results  are  of 
occurs  in  that  class  frora  which  che  Hospital  wards  are  recruited 


h. 

0. 

d. 

e. 


18 

1.  The  Fissure  of  Rolanrlo  communicated  with — 
a.  Fissure  of  Sylvius,  in  8  completely,  in  7  incompletely. 
h.  Frontal  sulci,  complete  in  12  ;  incomplete,  9. 
c.  Inter-parietal  sulci,  complete  in  7  ;  incomplete,  9. 

2.  The  Fissure  of  Sylvius  joined — 

a.  The  F.  R.  [see  above.] 

b.  The  frontal  in  20. 

c.  The  inter-parietal,  complete  in  26  ;  incomplete,  8. 

d.  The  Ist  temporal,  in  lo. 

3.  The  Inter-parietal  united  with— 
a.  The  i^.  72.  [see  above]. 

The  F.  S.   [see  above]. 

The  parieto-oceipital  in  18. 

The  horizonal  or  sup.  occipital  in  14. 

The  Ist  temporal  in  19. 

4.  The  Cnlcarine  entered  the  scissura  hippocampi  m  25. 

5.  The  calloso-marginal  joined  the  par. -occipital  in  1. 

6.  The  parieto-oceipital  joined — 

a.  The  inter-parietal  in  18. 
h.  The  horizonal  occipital  in  -3. 
From  these  limited  observations  we  may  conclude 

1.  That  a  considerable  proportion  of  the  brains  of  Hospital 
cases  are  of  the  confluent  fissure  type. 

2.  The  chief  difference  to  be  noted  between  Prof.  Benedikt's 
series  of  criminals'  brains  and  those  which  I  have  just  gone  over 
is  the  somewhat  greater  number  of  unions  between  typical  fissures 
more  particularly  between  the  fis.  Rol.  and  contiguous  ones! 
Thus  in  his  set  this  fissure  ccn.nected,  completely  or  incompletely, 
with  the  fis.  Syl.  in  24  instances  ;  in  my  series  in  only  10.  In  the 
other  fissures  the  disproportion  is  not  nearly  so  great. 

3.  Considering  the  number  of  brains  of  ordinary  Hospital 
patients  which  present  in  some  degree  the  confluent  fissure  type, 
it  would  seem  more  reasonable  not  to  assign  as  yet  any  special 
significance  to  it  until  we  have  fuller  information  about  the 
arrangement  of  the  convolutions  in  the  various  races,  and 
until  a  much  larger  number  of  the  brains  of  criminals  of  all 
countries  have  been  examined. 


I  t 


;1y 


'*■! 


i 


14 

Professor  Bcnodikt's  cases  wore  nearly  all  Slavonians  or  Hun- 
garians, and  though  Betz  of  Kioff,  a  leading  authority,  acknow- 
ledged the  atypy  of  his  si.eciincna,  it  would  have  been  more  satis- 
factory to  have  had  a  comparison  between  these  specimens  and  an 
e(jual  number  taken  from  law-abiding  members  of  the  same  races 
It  may  be  urged  that  in  Hospital  patients  the  brains  should  con- 
form m  considerable  numbers  to  this  2nd  or  confluent  fissure 
type,  as  many  of  them  are  individuals  in  the  lower  ranks  of  life 
and  not  a  few  belong  to  the  criminal  class.     This  applies,  how- 
ever, much  more  forcibly  to  dissecting-i'oom  material,  which,  as 
Dr.  Benedikt  says,  "  consists  of  the  remains  of  those  who  have 
suffered  complete  shi])wreck  in  life  through  low  grade  of  intelli- 
gence, imperfect  motor  development,  or  through  crimes  and  vice  " 
In  the  series  of  brains  which  I  examined,  there  were  no  dissect- 
mg-room  specimens,  and  it  di.l  not  include  the  brain  of  any 
notorious  criminal  so  far  as  I  am  aware. 

As  to  how  far  confluence  of  fissures  is  indicative  of  a  low  type 
of  cerebral  organization  we  also  Avant  fuller  information.    When 
existrng  mhigh  degree,  there  is  certainly  an  absence  of  many 
important  annectants  or  bridging  areas  of  brain  substance   but 
when  we  consider  the  variable  size  of  convolutions  boundin.^  the 
typical  fissures,  it  is  easy  to  see  that  defect  in  one  part  mi«ht  be 
niore  than  compensated  for  by  excess  in  another  part,  and  even 
a  nejghbourmg  part.  In  several  of  the  brains  which  I  examined 
no  aMy  No.  10,  the  confluent  fissure  type  existed  in  an  o^l' 
with  a  rich  convolution  system.     In  the  brain  of  Moreau,  the 
retro-centra    fissure  on  the  left  side   was  separated  from  the 
inter-parietal  by  a  distinct  gyrus,which  might  as  well  be  regarded 
as  an  excess,  as  absence  of  an  annectantand  confluence  of  two 
fissures  might  be  considered  a  defect 

With  reference  to  the  type  of  four  frontal  convolutions  which 
Plot.  Benedikt  has  found  in  such  a  large  number  of  his  spec 
mens,  I  will  only  say  that  in  10  of  the  hemispheres  examin  d 't 
was  observed  in  a  greater  or  less  degree  of  LelopmenT    N 
^^fe.e  was  )t  better  seen  than  in  the  brain  of  Ilayvern      To 
enter  upon  the  anatomical  significance  of  this  would  be  beside 
the  question  on  this  occasion. 


16 

Professor  Benedikt's  conclusions  arc  those  of  a  thorough- 
going somatist,  who  wouM  brin;^   all   human  conduct   within 
the   range   of   organic  action.  "  The  constitutional  criminal  " 
bo    says,    "is   a    burdened    individual,    and    has    the    same 
relation  to  crime  as  his  next  of  blood  kin,  the  epileptic,  and  his 
cousin,  the  idiot,  have  to  their  encephalopathic  conditions." 
And  again,  "  the  essential  ground  of  abnormal  action  of  the 
brain     (i.e.,  I  take  it,  bad  conduct,)  "is  abnormal  brain  struc 
ture.     His  44  criminals  were  what  they  wee  because  of  defects 
in  the  organization  of  their  hemispheres  :   thoy  belonged  to  the 
ennnnal  variety/  of  the  fjenus  homo.  No  wonder  he  says  "  that 
this  proposition  is  likely  to  create  a  veritable  revolution  in  ethics 
psychology,  jurisprudence  and  criminalities."     He  wisely  adds 
that  It  shouhl  not  yet  serve  as  a  premise,  and  should  not,  for  the 
present,  leave  the  hands  of  the  anatomists,  since  it  must  be  re- 
peatedly proven  before  it  can  finally  rank  as  an  undoubted 
addition  to  human  science. 

Crime  is  commonly  regarded  as  the  result  of  yieldin-  to  an 
evil  impulse  which  could  have  been  controlled  ;  and  this  element 
of  possible  control  is  what,  in  the  eyes  of  the  law,  separates  the 
responsible  criminal  from  the  irresponsible  lunatic.     The  belief 
m  a  criminal  psi/chosis  is  spreading,  and  is  the  outcome  of 
sounder  views  of  the  relation  of  mind  to  brain  ;  and  these  investi- 
gations of  Prof.  Benedikt,  to  which  I  have  so  frequently  referred 
may  serve  as  a  foundation  to  a  natural  history  of  crime.     But 
if  this  is  the  case,  how  are  we  to  regard  our  criminals  ?     What 
degree  of  responsibility  can  be  attached  to  the  actions  of  a  man 
with  a  defective  cerebral  organization  ?     Where  is  there  scope 
to  eschew  the  evil  and  to  do  the  good,  when  men  arc  "  villains 
by  necessity,  fools  by  heavenly  compulsion,  knaves,  thieves  and 
treachers  by  spherical  pre.lorainance."     Any  one  who  believes 
that  with  all  our  mental  and  moral  processes  there  is  an  unbroken 
material  succession,  must  consistently  be  a  determinist,  and  hold 
with  Spinoza,  that  '•  in  the  mind  there  is  no  such  thing  as  abso- 
late  or  free  will,  but  the  mind  is  determined  to  will  this  or  that 
by  a  cause  which  is  determined   byanthcr  cause,  this  by  yet 
another,  and  so  on  to  infinity."     For  a  long  time  to  come,  how- 


1 

h 

1 

\ 

s 

A 

mM 


J. 

16 


ever,  the  rm.jorhy  of  inJividuals — includin;^  some  who  arc  incon- 
sistent in  so  (Icing — will  continue  to  hold  the  intuitiouisf.  view 
jiowherc  better  expressed  than  hy  Shakespeare,  when  he  puts 
into  the  mouth  of  that  arch-criminal,  lago,  the  words  :  "  'Tis  in 
ourselves  that  we  are  thus  and  thus.  Our  l)odies  are  our  gardens 
to  the  which  our  wills  are  gardeners ;  so  that  if  we  will  plant 
nettles  or  sow  lettuce,  sot  hyssop  and  weed  up  thyme,  supply  it 
with  one  gender  of  herbs  or  distract  it  with  many,  either  to 
liavc  it  sterile  with  idleness  or  manured  with  industry,  why,  the 
power  and  corrigible  authority  of  this  lies  in  our  v,'ill.  ' 

"  Theft  and  murder,"  as  Huxley  well  says,  "  wovld  bo  none 
the  less  objectionable  were  it  possible  to  prove  that  tliey  were 
the  result  of  the  activity  of  special  theft  and  murder  cells  in  the 
grey  pulp."     One  thing  is  certain,  that,  as  society  is  at  present 
constituted,  it  cannot  afford  to  have  a  class  of  criminal  automata 
and  to  have  every  rascal  pleading  faulty  grey  matter  in  extenu- 
ation of  some  crime.     The  law  should  cntinue  to  be  a  "  terror 
tu  evil-doers,"  and  to  let  this  anthropolofioal  variety  (as  JBene- 
dikt  calls  criminals)  know  positively  that  punishment  will  follow 
the  commission  of  certain  acts,  should  prove  an  effectual  deter- 
rent in  many  cases,  just  as  with  our  dogs,  the  fear  of  the  whip 
exercises  a  restraining  influence— immediate  as  well  as  prospec- 
tive— on  the  commission  of  canine  crimes. 


Par.oc  Fi 


Fis-Calea 


Fig.  I. 


Plate 


Hg.  2. 


H- 


Ih  ,i  ;.   »4 


!■ 

■^11^ 

■ 
■ 

(I' 

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Inter 


Par  oc  fin 


Fig    3. 


Plate  2 


R«tri)-c«it  fii. 


liTrsul- 


l-'Tr  sul 


/n(er  jxarfii 


Par.ocfis 


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y^  LVt 


CASE  OF  Or.LlTKKATION  OF  THE  POKTAL  VEIN 
(PYLEPHLFlUTiS  ADIIESIVA).  P.y  William  Oslei;, 
M.D.,  M.P.C.P  Lond.,  Professor  of  the  Institutes  of  Medicine, 
MeGUl  University,  ALontreal. 

Thrombosis  and  suppurative  pylephlebitis  are  the  affections 
most  commonly  met  with  in  the  portal  vein.  A  few  instances 
of  culcitication  and  extreme  fibroid  thickening  of  tlie  walls  art- 
reported.  Organic  occlusion,  by  conversion  of  the  vein  into  a 
fibrous  cord  or  mass  of  connective  tissue,  is  a  very  rare  lesion, 
as  in  cases  of  thrombosis  life  is  usually  terminated  long  before 
organisation  of  the  clot  -an  take  place.  Tlie  following  instance 
of  it  presents  many  interesting  features,  anatomical  and 
clinical : — 

J.  C,  aged  28,  admitted  into  the  General  Ilospital,  under  my 
care,  June  17th,  18S1,  in  a  condition  of  extreme  exhaustion,  con- 
se([uent  upon  loss  of  blood  by  vomiting.    My  liouse-physician,  1  'r 
Andrew  Henderson,  obtained  from  him  tlic  following  history: — 
Has  always  been  strong  and  healthy;  somewhat  intemperate,  but 
a  steady  worker,     lias  never  had  syphilis.     No  constitutiomil 
disease  in  his  family.     Last  September,  when  engaged  in  some 
very  hard  work,  was  obliged  to  give  n]i  on  account  of  weakness 
and  dull  heavy  ])ain  in  the  up])er  region  of  the  belly.     It  was 
nevi'r  very  localised,  and  was  not  aggravated  by  eating.     Patient 
had  to  be  in  bed  most  of  the  time,  and  at  about  the  end  of  a 
month  had  an  attack  of  h;ematemesis,  vomiting  more  than  two 
quarts.      Did   not   leave   his   bed   for   some  %\eeks ;    does   not 
remember  whether  his  legs  or  abdomen  were  swollen.     Did  not 
go  to  work  until  about  April,  when  he  got  employment  in  a 
manufactory  as  iirejuan.     Latterly,  he  was  put  to  heavy  work, 
piling  bags  of  sugar,  and  yesterday  (l(itli)  he   had  to  give  uj) 
owing  to  feelings  of  great  weakness.     Tliis  morning  he  vomited 
a  large  quantity  of  blood,   partly  iluiil,  but  mixed  witli  ch)ts. 
When   admitted  in  i\w   evening   he  was   in   a  state  of   great 
exhaustion;  surface  lilaiiclit;d  ;  imlsc  veiy  small — l.'JoiLe 


tun 


100'^ 


'm]iera- 


respirations,  20.     Shoitly  after  getting  to  lied  h 


vomited 

(iadaver: 

June 

the  folk 

cular  m 

state,  bu 

no  distc 

oedema  i 

flattened 

tion ;    01 

forcible, 

tatit)n  a  i 

the  navel 

to  (he  rii. 

Thci'e  wa 

felt ;    are 

iletected  i 

axillary  li 

dulness   i 

directions 

examinati 

pile,  filled 

Urine  clen 

19lh. 

i)right,  li(ji 

the  neighb 

Imt  rallied 

tion  at  th 

nnirmur  w 

20tli.     } 

ency  to  de 

was  very  p 

On  the  2 

exhaustion, 

On  tlie  2;!d 

which  he  di 

Aulopsi/.- 

of  abdonum 

In  abdon 


i 


<ASK    OF    OHMTKKATION    OK    TIIK    l-QIITAL    VKIx.  209 

vumite.1  about  Ibnr  ounces  of  .lark  altered  blood.     A  i.eculiar 
(cadaveric  odour  was  noticed  in  the  breath. 

June  ISth.     At  the  morning  visit  patient  was  examined,  and 
the  followmg  condition  noted  :-He  is  a  large,  well-n.ade,  nus- 
cu  .r  man  ;   hes  on  his  left  side  in  a  drowsy,  semi-conseious 
state  but  can  be  roused.     Face  and  general  surface  blanched- 
no  distonsunr  of   abdomen;    superficial  veins   not  visible;    nJ 
aHen.a  of  the  feet.     Exann-nation  of  chest,  negative;  aMnncn 
flattened;   skm  of  niarble  whiteness  ;   visible  ^'pigastric  pu" 
lon ;    on    palpat.on,   nntrked    pulsation    in    umbilical    re-ion 
forcible,  vertical  m  direction  ;  no  tumour  to  be  felt.     On  anscnl- 
tatu.n  a  ren.arkable  double  murnmr  was  heard  midway  between 
he  navel  and  t,p  of  ensiform  cartilage;  to  be  heard  also  a  litt  e 
to  the  r,ght  of  the  middle  line,  but  was  very  feeble  to  the  lef^ 
-re  was  not  a  cardiac   murmur.     Zfa.-edoe  could  not  be 
dt;    aea   of    dulness   nmch    diminished;    could   scarcely    be 
detected  m  sternal  l,ne;  was  ;]  cm.  in  mammary,  and  4  cm  in 
axillary  Imes.    ,S>...-„ot  to  be  felt  below  costaUorder ;  ai^ 
.  ulness   increased,  11    cm.   in   vertical,   13   cm.   in   transverse 
'In'octions.      J>at,ent    di,l    not   complain   of    p,in    durim..        J 
.xannnation      Jiowels  have  not  ],een  moved;  a  lai^e  e>;terna^ 
f:  "";"'  w.th  coagula,  was  found  on  the  right  mar^n  of      ^  ^ 
brine  clear,  and  normal. 

19lh      During  tlie  night  patient  vomited  a  large  quantitv  of 
>v.J^ht  lapud  blood,  soaking  the  bed  and  covering  the  t^  " 
1H|  neigh  ourho.d.     He  was  ibund  in  an  apparen^v^in!"  a " 
;>'t  -ll.ed  on  the  administration  of  stimuLmts.     The  exaW  ' 

t-  at  the  visit  did   not   elicit  any  new  facts;  tlie     j^Z;^ 
iinirmur  was  not  so  distinct.  ^  'f,-i^Lnc 

20tli.     No  further  hu.niorrhage,  debility  extreme,  and  a  tend- 

On  the  21st  and  'I'M  patient  remained  in  a  state  of  profound 

;;;2;;;;^^;---e^-epeated  syncopal  attacks,  dui4!me  of 

oit!^!Z::^:t'  "'"  ■'--!-' ^^J-"Wn,nched;  no  distension 
of .  Hi  n  en  ,  cu  aneoiis  ven.s  not  visible ;  slight  cedema  of  feet 
i"  abdomen  the  coils  of  small  intestines  were  of  a  very  d    b 


h 


•I 

:i 


r.  'ill 

Ir 

t 

i  i 

■   II 

210 


lU;.    WILLIAM   OST,Kf;. 


slate  colour ;  ppritoneum  smootli ;  colon  distended ;  no  exuda- 
tion ;  liver  and  spleen  did  not  appear  below  the  costal  border. 
In  thorax  a  few  ounces  of  serous  fluid  in  each  pleura. 

Heart  was  flabby  and  pale ;  chambers  contained  small  clots ; 
valves  were  healthy.     Aorta  normal. 

Lvngi  pale,  a;deniatous  at  bases. 

Splcai  greatly  enlarged ;  weighed  67")  gnus. ;  was  intimately 
adherent  to  the  diaphragm  and  stomach.  Capsule  was  very 
thick,  in  places  wrinkled,  and  a  firm,  semi-cartilaginous  plate 
existed  at  its  convex  border.  On  section  organ  cut  with  great 
resistance,  creaking  under  *lie  knife;  the  trabeculai  thickened, 
rough,  and  in  spots  gritty.  Some  of  the  veiris  were  dilated,  and 
contained  thrombi.  Near  the  hilus  was  a  wedge-shaped  calcified 
mass,  the  size  of  a  walnut.  The  artery  was  very  tortuous,  and 
at  the  hilus  presented  a  group  of  small  saccular  aneurisms,  the 
size  of  large  peas ;  the  coats  thickened,  partly  calcified,  and  one  of 
them  contained  an  old  thrombus,  which  had  softened  in  the  centre. 

TAvcr  small,  and  closely  united  to  the  diaphragm  and  to  the 
abdominal  wall  on  the  right  side.  It  measured  25  cm.  in 
breadth  and  16  cni.Jrom  front  to  bade.  The  shape  was  retained, 
but  the  left  lobe  was  almost  completely  atrophied,  only  a  small 
thin  tonguelet  remaining.  Tlie  surface  was  smooth,  but  towards 
the  right  border  and  behind,  many  fibrous  bands  passed  between 
the  capsule  and  the  diaphragm.  The  capsule  on  the  under 
surface  was  oparpie  but  smooth.  On  section,  tissue  uniform,  pale 
reddish-l)rown  colour;  acini  distinct,  but  no  perceptible  increase 
in  the  inter-lobular  tissue.  The  anterior  border  and  the  remnant 
of  the  left  lobe  were  firmer,  and  the  connective  tissue  strands 
between  the  lobules  could  be  seen.  The  h.eimtic  veins  were  of 
full  size.  Portal  canals  not  numerous,  small ;  artery  and  duct 
distinct  (condition  of  portal  vein  will  lie  described  under  venous 
system). 

Microscopic  examination  showed  the  liver  cells  to  be  some- 
what fatty ;  the  connective  tissue  on  the  greater  portion  of  the 
right  lobe  was  not  specially  increased,  l)ut  at  the  anterior  border 
and  in  the  small  portion  of  the  left  lobe  th.  secreting  substance 
was  a  good  deal  atrophied.     , 

Gall-hladdcr  contained  a  (quantity  of  yellow  bile.  Gall  duct 
normal.     Hejiatic  artery  almost  double  the  usual  size. 


Stomm 

li([uid  m 

could   1)0 

here  and 

were  two 

end ;  the 

wer(!  scan 

memlirani 

Tntcstin 

ont.     Eec 

the  sphint 

tion  of  enl 

Kiihici/t 

quantity  c 

and  bladdc 

VenuuH 

the  portal 

beyond  its 

with  ill-de 

tissues.      I 

]ienetrated 

the;  natural 

tlie  tissue  v 

colour.     Tl 

taceous   or 

organ   were 

sheath  was 

duct  in  the 

any  special 

in  immediat 

The  remaini 

in  the  follo\ 

splenic  and 

tion,  the  siz 

there  a  calci; 

with  the   ui; 


'"^ 


CASK   OF   ODMTERATION   OF  TFIK   PORTAI,   VKiy.  211 

Stomach  was  capacious  and  containe.l  a  quantity  of  dark 
I.<1-.I  -Kxcd  wjth  food.  Veins  Loneatl.  the  muscular  coat 
-uld  l.e  seen  dilated  and  tortuous.  The  n.ucosa  was  pale 
horo  and  there  znarked  with  spots  of  capillary  injection.  There 
were  wo  snudl  superficial  losses  of  substance  near  the  cardia 
end  the  tissue  about  them  was  not  injected,  and  their  bases 
^vele  scarcely  as  deei.  as  the  submucosa.  About  the  pylorus  the 
membrane  was  manunillated,  and  on  section  very  toul-h 

Mcstmes  contained  dark  tarry  fa-ees;  mucosa  pafe  ihrou^^h- 
out.     Eectunr  presented  a  number  of  enlarged  veins  just  within 
ho  sphmctn-  and  the  external  tumour  was  found  to  L  a  collec 
turn  of  enlarKod  and  thrombosed  veins. 

Khhin,s  of  normal  size,  pale,  a  little  firm.     On  section  a  Uv.o 
quantity  of  thin  watery  fluid  oozed  from  the  su    a  I  Z 

iiiul  bladdw  normal.  I'^eter 

r««,,,,,  .Vv«.-0„  dissecting  tlie  gastro-I.epatic  omentnm 
1.0  l».rtal  v.n,  was  tou.ul  to  W  obliterated  from  a  „oi„t  2    n 

Sh'iiViis;''';"'  -"'"r*'' '"'°  "■■  '-«"'-■.  «brou,  c  :; 

tiMo  ,s      I,    tins  stato  ,t  .ntcreJ  tlio  l,il„s  of  the  or-an  a.-il 
ronotratcd  tl,e  n.ain  divisions  of  the  portal  canals ;  „o°tr ace " 
t  ,c  natnral  a,>,,car„nce  of  a  vessel  could  he  seen.     On  seetion 
e  «„e  „s  spongy,  not  indur.ated,  and  son.ewhat  redd,'      „ 
colon,.     Ihe,.e  we,v  no  ,cnnant.s  of  a  thro.nhns,  nor  any  crc- 
taoeons  or  ca  e.hed  portions.    The  main  brand,  s  withi,^  t  e 
.  Sa,,    were  also  ocelnded  ;    the  connective  tissne  of  GI  "so,  ■ 
lie  th  «s  ahnndant,  and  firn.er  than  nonnal.     Both  arte  y  a, , 
■luet  rn  those  parts  conld  be  slit  open  readily.     There  wis  not 
any  special  eonfaetion  abont  the  l,il„s,  and  iL  liver  snbstanc! 
...  ".....ed,ate  neigI,b,a,rho„d  of  the  portal  canals  looke.,    .1, 
li.e  rema,n.„g  p„rt,on  of  the  portal  vein  and  its  branches  Ce 
...  the  followtng  condition  :_J„st  bey.a.d  the  junction  rf, 
plcn,e  and  snpeno,^   nresenteric  was  a  large    saccular  d  lata 
...-.  tl.e  s..e  of  a  walnut,  with  thickened  ^alls,  and  he,t  a    I 
tl.    e  a  calched  plate  beneath  the  intin.a.      It    vas  i„  co„ta"t 
^•.ti.  the  under  surface  of  the  right  lobe  close  to  0  e   1     ,s 

If'";"  "•  P""";.-,  presented  several  small  sacenli,  the  h  t    t 
'^fwb.cl.    conta.,.ed    atbennnatous    plates.       The    mcse, 


"    !'■  ' ' 


r  ■ ' . 


:»f 


1 

1     \ 

i 

.' 

I  liij 


5       .     lilii 


212 


])!!.    AVILI.IAM    nSLEI!. 


1  raiiclies  worn  TiKidtiratcly  eiilar^'od.     Splenic  vein  admitted  tlie 
index  finffcr  freely,  and  all  its  branches  were  dilated.     .Several  of 
tliose  on  the  anterior  margin  of  the  spleen  were  fnll  of  firm 
tlironihi.     The  vasa  brevia  iVoni  the  fundus  of   stomach  were 
dilated,  and  some  of  the  larger  branches  contained  tbrombi.   The 
left  gastro-ei)iploic  was  almost  as  large  as  the  splenic,  and  at  the 
curvature  presented  several  large  dilatations,  one  of  which  ad- 
mitted the  top  of  the  thumb.     The  gastric  vein  emptied  into  the 
dilatation  just  beyond  the  junction  of  the  superior  mesenteric 
and  splenic,  and  was  nlso  enlarged.      The  walls  of  all  of  these 
vessels  were  thickened,  the  intima  a  little  roughened,  and  in 
spots   ciilcified.      The    i/iferior   mesenteric  was  moderately  en- 
larged;  the  hasmorrhoidal  branches  were   distended.     Inferior 
cava   noruifil ;    openings   of    hepatic   veins    presented    nothing 
unusual.       Among  its  branches  the  lumbars   a])])eared   large, 
particularly   one   passing   by   the   side   of    the    third    lumbar 
vertebra.      To  the  left  of  the  aorta  w\is  a  large  vein   nearly 
cfpial  in  size  to  the  inferior  cava ;  it  terminated  below  by  two 
branches,  one  of  which  ])assed  over  and  joined  the  junction  of 
the  external  and  internal  iliacs  on  the  right  side ;  the  other 
joined  the  connnon  iliac  of  the  left  s'  le.     The  ap})earance  of  the 
}/arts  after  dissection  suggested  a  diuible  inferior  cava.      Unfor- 
tunately the  liver,  together  with  stomach,  pancreas,  and  spleen 
bad  been  removed  before  this  condition  was  detected,  so  that 
the  upper  termination  of  this  vessel  cotihl  not  be  made   out. 
Two  large  branches  joined  it  above,  but  their  connection  could 
not  be  traced.      The  Uieiea  were  large  ;  nuiny  of  the  branches 
of  the  internal  divisions  were  thrombosed.     The  (liiqj/irai/maiic 
veins    formed  ;i  close   plexus,  particularly  in  the   o'soi)hageal 
region,  which  uuiterl  with  the  veins  of  the  coronary  and  lateral 
ligaments  of  the  liver.      The  lesopliagcol  veins  were  numerous 
and  large,  and  formed  a  rich  netwoi'k  about  the  curdia.     The 
veins  in  the  suspensory  or  round  ligaments  were  not  dilated.    In 
the  thorax  the  lower  intercostal  veins  were  veiy  large,  parti- 
cularly one  running  along  the  lower  margin  of  10th  rib.      Tiie 
vena  .'cjjfjos  major  almost  equalled  the  inferior  cava  in  width, 
and  admitted  the  index  finger  easily;  the  azygos  minor  was  also 
of  large  size. 
lleiiiarU—^\\v\\  a  case  as  the  above  presents  nuxiiy  points  of 


CASK   OK   ODUTEIUTION   OF   Till.;    l-OItT.VL   VEIN.  213 

interest.  SucMeu  and  violent  La-mateniesis  in  a  yoiu..^  nian  • 
no  a.sc:tes  no  enlarged  abdon.inal  veins,  sn.all  liver/large'spleen' 
HHd  a  locahsed  nu.rnuu.  in  the  epigastric  region-lhe  diao.noS 
was  no  easy,  btit  it  lay.  I  thought,  between  cirrhosis  ^f  the 
hver,  splenic  anremia,  and  an  aneurisn.     F.,  ei,rho,sis  as  a  cause 

V  1  moTi;  ""•"  """^T-^'^f  ^-y  ^f  spirit-drinking,  din.inished 
^.  lume  of  hver,  increase  in  size  of  spleen,  and  the  existence  of 
piles  ;  against  were-the  age  of  patient,  and  the  absence  of  many 
iniportant  signs,  as  gastric  or  intestinal  catarrh,  ascites,  and 
enlarged  veins.  The  well-nourished  state  of  the  man  tl 
nuderate  enlargement  of  the  spleen,  and  normal  aspect  o    the 

splenic      Ihe  suddenness  of  the  attack,  tlie  brightness  of  the 
vomited  blood,  together  with  the  existence  of  a  localised  murmu 
m  the  epigastric  region-the  origin  of  which  remains  obscure- 
suggested  the  occurrence  of  a  small  aneurism,  either  of  the  aorti 
or  cnie  of  the  branches  of  the  celiac  axis;  but  the  Ine^lrlL    t 

ot  the  live    and  spleen,  seemed  fatal  to  this  view.      Altoo.ether 
-  spite  of  the  absence  of  many  of  the  important  sym^    ^  ^ 
usually  present,  the  most  satisfactory  diagnosis  appeared'to  1 
l.ortal  obstruction  from  cirrhosis.      The  evident  reduction  in  the 
volume  of  the  hver  was  strongly  in  favour  of  this  view,  and  as  I 
hud  also  met  with  several  instances  in  which  severe  luemorrha.e 
uKl  been  the  initial  symptom,  I  was  the  more  inclined  to  reoaPc 
It  as   an  auoimdons  case   of   this  nature.       The  history  of  a 
lueniorrhage  in  September,  followed  by  an  obscure  illness  of  some 
months  duration,  pointed  to  a  chronic  malady 

jll.o  history  of  the  case  offers  no  clue  to  the  cause  of  the 
obliteration  of  the  vein,  but  we  may  suppose  it  to  have  taken 
place  m  the  way  in  which  veins  usually  become  occluded,  vi. 
by  1.0  formation  of  a  thrombus  which  organised,  and  was  ulti'-' 
.  e  y  converted  into  a  fibroid  cord.  Apart  from  marasmatic 
cund.  ions,  in  which  portal  thrombosis  occasionally  occurs 
coagula  ion  of  blood  in  the  portal  vein  is  met  with-lst,  1^  an 

1  in  tumours  in 


of  tlie  liilus,   which  coi 


iipress  the  main  trunk 


^!l)atic  omentum ;  2d,  by  extension  of  infl 


neighbourhood 
in  the  gastro- 


iunmation  from  tl 


if  ■ 


,1 


HI 


A: 


le 


ii\i 


K  » 


214 


IMf.    WILLIAM   OSLKI!. 


jB  B  I. 


bile  passarrps,  as  in  cholangitis  from  ohstruction  by  gall-stones  ; 
and  .''.d,  b}^  tlie  extension   of  inflaniniation  or  transference  of 
emboli  from  suppurating  or  ulcerative  foci  in  tlie  territory  of  tlie 
portal  vessels,  but  in  these  instances  the  thrombi  wjiicli  form 
rapidly  soften,  and  supi)urativo  i)ylephlcbitis  is  the  result.     I 
have  met  with  cases  of  pylethrombosis  from  the  above  causes, 
but,  so  far  as  can  be  ascertained,  none  of  them  have  prevailed  in 
this  case.     The  only  possible  source  which  is  suggested  by  the 
post-mortem  is  the  cretaceous  area  in  the  spleen,  reiu-esentin"  the 
final  stage  of  a  small  abscess  or  infarct,  which,  when  in  an  active 
state,  might  have  induced,  by  direct  extension  or  embolism,  the 
pivletjirombosis. 

The  state  of  the  liver  is  worthy  of  note.     Though  shrurd<en 
particularly  in  left  lobe,  the  greater  part  of  the  organ  was  smooth 
and  not  in  the  least  ciirhotic.     In  the  few  instances  of  chronic 
occlusion  which  have  been   reported,  the   condition    has    been 
variable.     In  Cruveilhier's  casoMn  which  the  obstruction  must 
have  lasted  for  years,   the  organ  is  described  as  smooth   and 
healthy.     In  others  it  has  been  cirrhotic.     Solowietf-'  has  pro- 
duced a  fibroid  condition  of  the  liver  l)y  inducing  occlusion  of 
portal  branches  in  the  dog,  but  that  this  is  not  "an  invariable 
se.pience,  in  man,  is  sliown  by  this,  as    well  as  other  cases 
Nor  IS  there  any  good  anatonucal  reason  why  it  .should  occur 
After  complete  exclusion  of  portal  blood  from  the  or-an  the 
lobular  capillary  plexus  continues  filled,  as  the  venules  w'hich 
collect  the  blood  from  the  capillaries  of  the  hepatic  artery  empty 
dn-ectly  mto  the  portal  interlobular  vessels,  and  the  l)loo(l-sun ply 
IS  in  this  way  maintained.     Hence  the  function  of  the  -dand  is 
not  materially  interfered  with,  and  bile  continues  to  be^formod 
from  the  blood  furnished  by  the  hepatic  artery,  which  may  as 
m  tins  case,  undergo  a  compensatory  enlargement.     That  the 
aiterialblood  caninthis  way  act  as  sub.stitute  for  the  portal 
supplj'  IS  wel    shown  by  such  a  case  as  the  one  under  consi- 
deration, winch  forms  an  interesting  counterpart  to  the  one  of 
aueunsm  of  the  hepatic  artery  ^  which  apparently  demonstrate,! 
that  the  converse  is  not  true,  but  that,  as  Cohnheim  and  Litten 


'  Alhw  (l\i,)(it.  jiKth.  livr.  xvi.  1 
"  Virchuw's  JrcJiiv,  l.\ii. 
'■'  Canada  Mnl.  a 


'"'■.'A  J'ii/i;ii(/,  ],s;;,  Dis    i; 


'>s<  and  Osier. 


State,'   t: 

be  compi 

There 

in  which 

occlusion 

nierous  c 

of   the  li 

branches 

means  of 

ised,  and 

balanced. 

that  the  e 

symptoms 

by    Sappe 

coronary  \ 

discharges 

also  conin 

passing  in 

and  in  the 

diaphragm 

ment  dihiti 

the  portal 

a  redistend 

the  small  \ 

I  have  rec( 

iiarrowin<>' 

O 

increased  I 
the  presenc 
(4)    certain 
lietzius,  wli 
anastomosii 
the  inferior 
exist  betwei 
In  this  cas 
carried  on 
There  were 
cesophageal 
liv(,'r  interco 

'    /  iiV/toir's  ^ 


CA.Sl.;   OF   OnLITEHATION   OK   TlIK 


I'OHTAL   VKIN. 


2\, 


stato.^   the  portui  blood  cannot  replace  the  hepatic  if  the  latter 
he  completely  excluded  from  the  organ. 

There  is  no  more  interesting  sul^ect  of  study  than  the  way 
in  wluch  channels   of  collateral  circulation  are   establishecr  a 
occlusion  of  hu-ge  vessels.     In  the  case  of  the  portal  vdn  n  w 
moro..  opport.,mtios  for  this  purpose  are  aObrded  in  ZlZ. 
of   the  hver,  m  winch  the   obliteration  of   many   interlobula 
branches  necessitates  the  development  of  circuitous  rouU^s  l; 
rneans  o    vvluch  the  blood-current  in  the  portal  systen.  is  e  Ll- 
sed  and  the  reduced  carrying  capacity  of  its  vessels  coute - 
ha  an  ea.  _     ,  ,,,,,  ,,,,^^,.^.^^^  ^^  ^^^^^^^^^  .^  ^^,^  con.pensat  on 
that   he  mrhosis  may  reach  an  extren.e  grade  without  produc  n 
symptoms.     These  collateral  channels  have  been  fully  lescrbd 
V   Sappey,  and  are  chiefly :_(!)  the  anastomoses  between    ho 
coronary  vems  of  the  stomach  and  the  oesophageal  plexus,  wh    h 
discharges   znto    the   lower  intercostal    and   a^.o!   veins    " 
alsocommumcates  with  the  diaphragn.atic  vessels;  (2) 'v 
passing  ,n  the  coronary  and  suspensory  ligaments  of  the  l^e 
ana  m  the  ad  es.ons  which  often  form  between  the  liver    nd 
diaphragm;  (,)  .n  some  cases  a  sn.all  vein  in  the  round  iZ 
ment  ch  utes  enorn.ously,  and  affords  free  conununication  betw^fn 
the  portal  vem  and  the  epigastric  vessels.     .Son.e  regard  t  las 
a  red,stended  umbilical  vein,  but  Sappey  states  thatlt  i 
he    nKall  vesse  s  wluch  he  describes  as  the  ..n.  poric  access^^ 
1  have  recorded  an  instance'^  of  advanced  cirrhosis,  with  --reat 
narrownjgof  the   portal   branches,  in   which  no  s^mpton^s  o 
ucreased  blood-pressure  existed  in  the  portal  systen.  owino-  'o 
the  presence  of  this  vein,  which  was  as  large  as  L  little  fin^e 
4)    certam    ven.s,  forming  what  is    known  as    the  system   If' 
Let.ms,  wluch,  ong.nating  in  parts  of  the  intestinal  canal   and 
anastomo.ng  with  the  radicles  of  the  portal  vein,  discharge'  i    o 
the  inferior  cava  or  its  l>ranches;  (5)  the  communications  which 
exist  between  the  superior  and  inferior  ha.norrhoidal  plexus 
In  this  case  the  collateral  circulation  appeared  to  have   b    n 
earned  on   by  the    first,    fourth,  and   fifth    of   these   channe  s 
Ihere  were  extensive  communications  between  the  g^.tric  and 
a'sophageal  veins,  an.I  through  the  latter  with  tl 


liv(;r  intercostals.     The  vasa  hi 


ic  azygos  and 


•ci 


Vurh 


hvir's  Avchiv,  Ixvii 


ia  and  others  about  the  fund 


us 


Monimi/  (lencndJIospUal  R,pufl.s,  1S8U. 


' 

-k' v:  >• 

?'-  ■.     '' 

1  , 

■;•  U"', . : 

!»■■  -l,' 

^,1:'"/ 

Hi 


liir. 


CASE   OK   OPLITKltATION    OK   TIIK    rOIJTAL    VKI\. 


of  tlio  stnni'icli  were  IiiVhly  tloveloiJinl,  atul  jdiiu'il   the  dense 
tKjtwi'i'k  tibijiit  tlie  OM'tlia  ami  tlie  tliiiplini^niu  in  lliu  inunediiite 
vi(.'inuy.     Many  of  these  hrai'.ches  were  pluy',iied  with  thrombi. 
Dunhtles.s  a  hirLje  share  in  the  supplementary  circulation   was 
taken  hy  the  vi'ins  of  the  system  of  lletzius  and  the  peritoneal 
branches  emptyin  '  into  the  cava.     The  lari^'e  vessel  to  the  left  of 
the  aorta  may  haV''  been  a  j^reatly  disteiuled  azvLjos  nunor  which 
Ilenle  iigures  as  ji)iiiinL(  with  the  left  iliacs,  but  unfortunately 
its  connection  couhl  not  be  made  out  owing  to  the  removal  of 
the  viscera  before  the  nature  of  Uie  lesion  was  suspected.     The 
l)lood  in  it  probably  r(;aclied  the  a/ygos,  which  was  of  large  size. 
In  the  case  of  obliterated  vena  cava,  recoi'ded  in  this  Juitrndl} 
1  mot  with  a  sinrlar  vein.     The    hu'inorrhoidal  ])lexuses  were 
not  greatly  distended,  but  the  branches  of  the  internal  iliacs, 
particularly  on  the  left  side,  were  very  large,  and  many  of  them 
contained  thrombi.     The  epigastric  veins  were  not  dilated. 

The  collateral  circulation  must  have  existed  for  some  time 
parhai)S  for  years,  and  was  fully  compensatory.  The  somewhat 
sudden  onset  of  the  final  symptoms  may  reasonably  be  attributed 
to  interference  with  this  free  cir  ulation  by  the  thrombi  in  the 
gastric  veins,  and  in  branches  of  the  internal  iliacs. 

*  Vol.  xiii. 


K  1- v/» 


%AI.(lr.  i».  .1.  r.„(rall.Ii.((  i;  i  „d.  \Vi,scnscli;ilk  1^  h  M. 


i"» 


,  !  • 


rebor  don  driftcii  Forn.bcstaiidtoil  don  nintos. 

Von  Prof.   Dr.  fls|,.r,  MeGill  Univorsitat.  Montreal, 
mitgeteilt  und   veroffeutlicht*^       T,        .  l        i  .  ''^^«y''^J-'''"«iety" 

das.  in  einen.  Tro  en  ut  ^',t"  !^""««"  '-^^^ten  es  uns  klar, 
wir  siets  die«e  KoSen  in  Hwl  •'""^^"?  I''''"  ««"«'"">«". 

der  anderen  Seite  n  e  Bh!uZT  'T^'''''"  /'"^<^«"'  ^vahrend  auf 
CapiUaren)  gan.  de"slo„  K  "  ^T"  «,^  ^'-^^ '•'«"'  Venen  oder 
einielte  ElL^ente  Sukn   d    Teineli  N^  ^''"' ^^•'"^'""  =^'^  ^-- 

des  Entziehen  efB  tes  dteh '  K  •  "'^t^  T  ""  Augenblick 
den^selben  sich   bewegt  haUen  ^^"''P^'-'^hen ,    d.e   vorher    frei    in 

dnm  Naiuen   ..8^        t±''  ...^'""^^"^^  vordemonstrirt  und  sie  unter 


diim  Nauien   „Sc  ul'liz,,',  gninul 
*)  s.  Proceedings  1874,  No.  153. 


ii'te  Massen"  und    „S 


«f><;ifnLTZKs 


r. 


H 


j'i  ._ 
•I  'I 


1: 1 '     I 
llrl  I 


(' 


'II 


KoiptMcliLMi"  (Mii^futiilirt.  Zweift'lios  I'jillen  sio  mil  Zimmichmann's 
Elt'iiKMitarkOrpercheii  iind  niit  IIaykm's  llilinatobluston  zu- 
Maiuiiiuii. 

NeiKntliti^ra  hat  Bizzu/mki*)  dieser  Sadie  fVisches  Intcre^irte  zu~ 
gowoiulet.  Walirenii  icli  jedocli  die  Riclitiifkeit  der  UeherHelirift 
Beines  AiifKatzes:  „Kin  iieuer  Formbestatidteil  des  Hlutos"  zu  be- 
anstaiiden  wnije,  ^'eHtelie  icli,  dass  ich  Tatsacberi  begc^fiiefe,  welche 
neiiie  Aiit^icht  bekraftigeii  iind  den  Eiiifluss  der  bere^rten  Kiirper 
auf  das  Geririneii  iiiid  die  Klimipunfonnation   dea  Bliites  dartiin: 

1)  Dis  Faser.xtoffnetz,  das  sich  aiif  der  (ilaspiatte  mis  dem 
IJliite  aiifseheidet,  ist  in  der  Kei^el  dicliter  uiid  starker  da,  wo  sich 
S(  iiri,izi;'s  Kleuieiite  am  zahlreiclisten  vorHndeii,  als  z.  IJ.  in  Schwache- 
I'iillen,   bei   Septhilmie,   Phthisis  u.  s.  w. 

'2)  Der  Veiliiuf  der  Endokarditis  Itrinirt,  \\ie  all^emehi  bekannt, 
fibriiiuse  Wucheruiigeri  hervor.     Ich  babe  in   nianchen  solchen   Aus- 

wCichsen  —    nio^fen    sie    warzi^er    oder    ulcerativer   Natur    sein    

runde  eorpusouhlre  Eleniente  j^ef'unden,  die  init  Sciiui.izk's  .,Kurnchen- 
liaufen"   identisoh  sind**). 

3)    Bei  eiiiein    alten  Manne,    der   an  Carcinoma    ventriculi    litt, 
W!ir    an    der  Aorta    ein   aul'serordeiitlicher  Befiind.       Hie    war    sehr 
iilberomalos  und  stellenweise  verkalkt.     Gerade  iiber  der  liil'urcation 
land  sicii  eine  grau-weiise  Masse,   etwat*  abgephittet,    3  —  5  Ctm.  im 
Dnrehniesser,    sich  jedoch    1,5  Ctm.   nber   den  Rand    eriiebend,    mit 
wehhem  sie  test  verwaaheen   war.     Es  sab  sich  wie  eine  Neubildung 
an  und  ich   liielt  es  anfani^s  fiir  eine  secundare  Krebsinasse,   welche 
die  A.ler  diirclibrochen  babe.      Nach  genauerer  Priifiing  zeigto  sich 
jedoch    (lie    i-anze  Masse  als  zusammengesetzt  aiis  kleinen   farblosen, 
eng  aneinarider  geschlosseneiiKorperchen,  die  in  )eder  Beziohim.r  sich 
identisch  mit  den  individuelleii  Klementen  von  Srmn/rzK's  „Kornchen- 
baufen-  verhielten.     Jede  Monuchkeit,    sie    irrtiimlicber'Veise    fiir 
veranderte  rote  oder  weifse  Bhitkorper  zu  balten,  war  nusge^chlossen 
Welter  ianden   sich    (i   oder   8  kleinere  Fiecken    an    der  Intima  auf 
einer  Balggeschwnlst  aufsitzen.l.      Das  Fasernetz    in    diesen   Massen 
war  nicht  erkennbar  und  an  keiner  derselben   befand   sich  coa'^uUr- 
tea  Blut.  '^ 

A  f^  '".  n'r'  ^^"^"  ''°"  ^"<?"'7sma  habe  ich  dieselben  in  grofser 
Anzahl  aut  Ihromben  sitzen  sehen.  Im  ersten  Falle,  be!  einem 
Aneurysma  der  Aorta  thoracica  von  geringer  Ausdohnnn^s  das  den 
Oesophagus  durchbohrt  hatte,  fanden  sich  merkwiirdig  verzwei-te 
iadengleiche  iilamente  auf  der  Oberflache  des  Thrombus,  die  sich 
schart  gegen  den  dunkelroten  Untergrund  abhoben.  Diese  Filamente 
waren  aus  den  beregten  ScHiMivK'schen  Korperchen  zusammengesetzt, 
unterrn.sciit  nut  Fibnnn.ederschlagen.  _  Der  zweite  Fall  vvar  ein 
giolses  Aneurysma  am  Aortaboge.i  Hier  erschie.ien  sie  auf  der 
aulsersten  Ablagerung  des  Thrombu.,  entbehrten  jedoch  .les  fadon- 
gleichen.  netzartigen  Ansehens. 


*)  i.  d.  BI    i.s82,  No.  -2,  lU  und  20. 
}  Ucbcr  ulcerative  Eudokarditis.     Skuu.n'.s  Arch,  of  mod.    1S«1,  Febr. 


Ueber  die  KntHtel.ung  dieser  Coipusoulu  winnen  wir  nichtn    aber 

.    „ n    *''«f  7' "'"••'  angenon.mei.   winl.     Auch  Cbei- ihren  Zweck 

vo  I u.mnun  hat.      In    einer   oben    erwilbr.ten   AbbniHlhin,r    nber  den 
b.M-  ..,•  en  Ge,.enHtan,l   beH.-brieb    und    .tollte    kh    aucb  noch  «ew  Ine 


I'i 


I 


Getlruckt  be!  L.  Schumacher  In  tietlTiu 


:■  m 

]  H 

^■■^m 

flR 

i^H 

^H 

,    ■    t    i^^^H 

■jT'l'^.'''  ^1 

ii  i^l 

SL 


CAS 


Gknt] 

cal  side 

syphilis  i: 

manifestf 

present  t 

study  to-i 

not  use  tl 

the  case  _; 

a  poor  \iO 

of  her  chi 

her  the  cj 

We  shall  i 

Case  I, 

snuffles  ar 

family  hisi 

but  not  sp 

of  the  chil 

The  chi 

trouble  ;  ii 

appeared  c 

an  eruptior 

•  Reported 


X  ^  vm 


SUMMER  SESSION  CLINICS 


BY 


WM.  OSLEP  M.D.,  M,R.C.R,  Lond. 

McGILL  UNIVERSITY. 


No.  I. 


CASES  OF  INHERITED  SYPHILIS/ 

GKNTLEMEN,-In  the  out-door  dcrartment  and  on  the  sur<ri- 
cal  side  yoiMvill  have  many  opportunities  of  seeing  acquired 
sjph.hsn.  Us  recent  forms.  The  inherited  disease  presents  many 
manifestations  which  come  under  the  pliysician's  care,  and  at  the 
present  time  I  have  three  examples  in  my  wards  which  we  may 
study  to-day  with  advantage.  And  first  a  word  of  caution.  Do 
not  use  the  tern  syphilis  before  your  patients,  particularly  as  in 
the  case  just  to  be  brought  in  of  a  mother  and  her  child.  Many 

oX  cl -r  7  '"'  "  ''"'"^  ^«""-'^"^^  ''  «-  P---  nature 
of  h  r  child  s  affection  until  an  incautious  word  ha   suggested  to 

We  shall  use  the  old  term  lues. 

J.m^  ^"7  K  ^' ""'-  ^  ^''^"'-  ^^'"'"^^  '"^  l^^l'  inst.,  with 
nuffles  and  skin  eruption.  Mother  has  been  married  twoy  ars ; 
ami^  history  good  ;  has  no  signs  of  disease  ;  nipples  were  sore 

bu   not  specific  ;  had  one  miscarriage  at  7  months;  the  father 

ot  the  child,  she  says,  is  healthy  (?). 

The  child  ^a,  5,,^  ;^^^^^^^^^  j^^^  ^^  ^^^^^^  ^^^  ^^^^.^ 

trouble  ■  m  two  weeks  began  to  snuffle  ;  at  four  weeks  spota 

appeared  on  the  body  and  about  the  buttocks ;  on  admission  had 

anmiption^  genitals,  face  and  nose.  The 

•  Reported  by  Mr.  C.  E.  Cameron. 


i  i-'   '    i 


J  I  ■'  'i 


'.  .l 


.  m 


1 
I ,, 


ii* 


If 


a 


■ill 

f  'I 


■11 


,*     i!i, 


2  StIMMKH    SKS.^IliN    CMNICS. 

eruption  consistoil  of  irrcguliir  blotches,  ami  about  the  anus  some 
soft  mucous  patches,  and  here  and  there  a  pustule.  The  patches 
were  erythematous,  and  the  scrotum  also  was  swollen  and  sore. 
About  the  mouth  the  skin  was  rough,  raw  and  red,  but  no 
pustules  nor  papules  could  be  seen ;  on  the  arms  and  hands 
papules  now  exist.  On  the  14th  inst.  was  given  gr.  I  Iljdrarg. 
cum  Creta,  t.i.d.,  and  a  piece  of  mercury  ointment  about  the 
size  of  a  pea  was  rubbed  into  the  skin  at  night.  Since  that  time 
the  child  has  improved  ;  the  eruption  about  the  face  has  faded, 
leaving  a  reddish  coppery  stain  ;  the  buttocks  have  also  improved 
in  condition ;  the  nostrils  arc  still  stuffed,  but  not  so  much  as 
when  first  seen  ;  no  distinct  mucous  patches  are  to  be  seen  in- 
side the  mouth. 

Now,  gentlemen,  I  would  ask  you  to  make  a  careful  study  of 
the  child.  Do  not  suppose  that  it  is  only  in  hospital  practice 
that  you  will  find  these  cases  ;  lues  is  no  respecter  of  persons, 
and  there  is  no  station  in  life  in  which  you  may  not  expect  to 
meet  it. 

Within  the  womb  the  foetus  may  be  blighted  and  abortion 
occur  at  the  fifth,  sixth  or  seventh  month.  If  it  affects  the  child 
in  utero,  as  a  rule  it  kills  there,  and  the  child  is  born  dead  ;  if 
not  affected  in  utero,  the  child  is  born  healthy,  and  in  about  two 
vfceks  it  begins  to  snuffle,  and  a  rash  appears  upon  the  buttocks  : 
there  may  be  also  a  rash  about  the  mouth,  and  this  may  become 
general.  About  the  buttocks  there  may  be  soft,  raised,  injected 
spots — mucous  patches.  The  above  ai)pearauccs  are  charac- 
teristic. 

To  *reat  this  condition  give  mercury,  the  mercury  and  chalk 
powder  in  gr.  I  doses  tin-ee  times  a  day,  and  rub  in  a  little  uf  the 
mercury  ointment  every  night,  or  the  latter  may  be  spread  on 
the  child's  flannel  )  oiler  ;  or  you  may  give  corrosive  sublimate, 
gr.  i  in  3vi.  of  water,  and  of  this  give  5i  every  three  or  four 
hours.     These  cases,  as  a  rule,  do  well. 

Infantile  lues  may  lead  to  characteristic  appearances  in 
the  child ;  the  eruption  causing  fissures  about  the  mouth, 
which,  when  healed,  leave  scars  which  radiate  from  the  angle 
of  the  mouth  to  the  cheek.   In  the  infant  before  you  the  present 


CASES   OF   INHERITED   SYPIIIlis.  3 

ra*  is  healing,  but  during  the  first  year  thco  may  l,o  ocea 
onal  skm  emptions,  or  mucous  patches  in  the  mouM,      If  tht 
clnd  survives  the  Brstyear  the  disease  usually  rema  „s  la  cut 
but  as  puberty  ,s  approached  again  declares  itself,  a    I  u™,' 
eft  'tl     "°'*  """  '°  ""  ''™="'"  '"■    N°"  «>»' '  «  PUentha 

™  ncd  tot-  :„,  that  he  is  at  fault.     What  l";."  rl™ 

hersel  ,  she  syph,  .cd  ?     Most  writers  ,l,i,*  that  a  «!„ 

ho!   ,    ,     '•"  °  '^'''"''""^  '=''''•' "  «°"'»"'inated  in  some  dc™ 

it:  ::t:r:::;rto'ThS,f  „'•"''■  ?:"  -^ - 
of  np3  it  would  «ive^he\lr:SL^:^r' -^r^^^^ 

IS  sometimes  known  as  Colles's  law. 

The  next  oases  illustrate  some  interesting  later  manifestations. 
Case  II.-Girl,  aet.  13,  showing  severe  ulceration  of  throat 

then  became  b  nd  •  cnrf^il  K,.  n..  n  n        ,        -^  »  '  ^"" 

tins  also  cured;.;  hid  t-retW^^^^  "T  ^^* '^^^' 

pain,  but  some  difficult;  irsTvl:;;::^'-  '^^  -"^'^^'  ^^  --^ 

/'m.«^  C.nrf^^.-.n.- Small;  welf  nourished  ;  has  not  th. 
syphilitic   countenance.      Teeth~JJnn<^r   .    T  i        •  ^® 

orndpri  nf  f»,„       1  ,   ^eec/i— Upper   central   incisors   are 

::uil  int:.rs'p;:ifiet:*'S"  T  '-t-™-^^^-  ^"' " 

fte  tongue  or  cheeC  Itt   he     r  Mlrf  """'"f  '  ""  "" 
ease  ;  the  uvul,  a.,d  veh™  are  .'„      ,b  "  """"""  *^- 


ii'i   1  :'*.-,'' 

^H 

.      '^    ' 

^H 

1 

)  ■ 

I'    ■ 

m 

1 

m 

i  ' 

i 

1 

j 

^^^1 

Iff*'"' 

ni! 

^E 

I           1 

',ll 

H 

)' 
I 

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SUMMER   SESSION   CLINICS. 


the  orifice  of  the  Eustachian  tube  ;  as  low  as  can  be  seen  in  the 
pharynx  on  the  posterior  walls  arc  cicatrices  with  reddish  fleshy 
outgrowths;  nothing  else  noticeable.  Ei/es  are  apparently 
clear,  but  on  careful  inspection  both  corneoe  are  seen  to  be 
slightly  turbid  and  hazy.  She  has  had  interstitial  keratitis,  a 
common  affection  in  secondary  syphilis,  which  comes  on  usually 
between  the  twelfth  and  sixteenth  year,  is  specific,  and  if  properly 
treated,  generally  curable.  Secondary  acijuired  lues  in  man 
rar-^ly  destroys  the  structures  of  the  throat.  In  the  inherited 
form  the  throat  afltction  is  apt  to  be  more  intense  and 
phagadcenie,  as  in  this  child.  Ear  trouble  is  not  uncommon 
in  inherited  lues.  In  this  instance  it  may  have  extended  from 
the  pharynx  ;  but  middle  ear  disease  may  occur  without  throat 
complications.  In  this  case  the  disease  in  the  pharynx  is  not 
progressing.  She  is  on  potas.  iodid.,  grs.  x,  t.i.d.  To  do  any 
good,  these  cases  require  early  and  energetic  treatment,  as  the 
ulceration  is  rajjid  and  destructive. 

Case  III.— Girl,  tet.  23,  admitted  Feb.  10th  with  Bright's 
disease  ;  dropsy  of  the  legs  and  face.  Family  history  uncertain. 
This  girl  presents,  as  evidences  of  inherited  disease,  large  tibial 
nodes,  onychia,  and  a  suspicious-looking  spot  of  ulceration  on  her 
forehead  Nodes  are,  in  acquired  pox,  common  on  the  forehead, 
clavicles,  tibiiiR,  &c.,  and  are  the  result  of  specific  periostitis, 
caused  by  virus  in  the  blood.  They  may  be  absorbed,  or  go  on 
to  the  formation  of  bone.  They  arc  also  important  features  in 
inherited  syphilis.  Nodes  produced  in  the  congenital  form  differ 
fr(>m  those  produced  in  the  accpiired,  inasmuch  as  they  affect 
more  often  the  bones  of  the  upper  and  lower  extremities,  are 
generally  symmetrical,  are  much  larger,  and  may  occur  over  the 
whole  extent  of  the  bone ;  they  are  rarely  painful,  and  often 
disappear  under  treatment. 

The  tibiae  of  this  girl  are  enlarged,  thickened,  and  misshapen: 
almost  a  uniform  node  from  ankle  to  knee.  The  fibula  on  the 
left  side  is  thickened,  especially  about  the  lower  part.  I  remem- 
ber, on  several  occasions,  hearing  Mr.  Hutchinson  call  attention 
to  the  fact  that  these  large  nodes  were  often  mistaken  for  Rickets. 
I  pass  around  one  of  his  plates  illustrating  this  form  of  node. 


CASES   OP   INHERITED   SYPHILIS.  5 

Teeth-Uv^ov  incisors  eroded  at  the  root ;    upper  ones  well 
forced  nothing  suggestive  about  the..     NaU.Z  the  thul 
nng  and  httlo  fingers  of  right  hand  are  mal-for.ed,  rou^h  dt' 
•l-scoloured,  scUy,  and  are  typical  instances  of  (^^./.v!  ;^.  a' 
or  psoriasis  of  the  nails.  '^  ' 

You  noticed  that  I  examined  the  teeth  of  these  two  cases  with 
spocia  care.  I  did  so  because  these  organs  so.etir^ 
valuable  oi-  even  positive  evidence  of  inherited  syphilis.  Mr 
Jonathan  Hutchinson  first  called  attention  to  thfsVact,  and  I 
have  here  for  your  inspection  his  Plates  illustrating  the  subject. 
ihe  teeth  in  case  II.  would  be  called  by  some  "specific,"  but 
they  are  not  so  and  I  gladly  take  this  opportunity  to  in  pres 

e  ver  ha   been  led  to  regard  as  distinctive.      At  the  Congress 

as  year  he  complained  very  justly  that  men  had  not  sufficiently 

tudied  lis  writings  on  the  subject,  and  were  too  apt  to  regard 

any  ma  formed  teeth  as  syphilitic.     The  facts  are  briefly  th^  : 

1,  leeth  giving  mformation  are  the  permanent  ones      2  The 

TaitdT  Tf "  T'T''"^  ^"^'"••^-  ^^  Characters'are  : 
d wai fed,  stunted  m  length  and  breadth,  and  narrower  at  the 
cutting  edge  than  at  the  root.  Anterior  surface  has  usually  the 
ename  well-formed  and  not  eroded  or  honeycombed ;  the  cut 
.ng  edge  presents  a  .inglo  notch,  usually  shallow,  sometimes 
deep,  and  m  that  notch  the  dentine  is  exposed 

of  ani;rT'".v"'""'"^  '^  ''''  surface,  are  indications 
0  an  eaily  stomaUUs,  an  inflammation  of  the  mouth,  perhaps 
from  mercury,  or  associated  with  convulsions  ^ 

Children  who  have   been  the  subject  of  syphilis  frequently 

f;:;:;t^%77?^--«^^-^-'P^>y«-gnomy!recognizible^ 
a  glance  Ihe  ollowing  are  chief  points  \n  ^  S^phimic  counte- 
nance :  1,  forehead  prominent,  especially  the  frontal  eminences  ; 
2  saddle-nose,  bridge  being  defective,  owing  to  early  coryza  and 
nflammation  ;  :],  often  striated  lines  from  corners  of  moifth,  and 
the  skin  is  colourless  and  rauddv. 


I 


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SUMMER   SESSION  CLINICS. 


n 


No.  II. 


ACUTE  BRIGIIT'S  DISEASE. 


Gentlemen, — Since  I  took  charge  of  the  wards  you  have 
had  opportunities  of  studying  three  cases  of  acute  nephritis,  and 
to-day  I  propose  that  we  shall  go  over  them  together,  and  see 
what  lecsons  we  can  learn  about  this  important  affection.  And 
first  let  me  remark,  that  under  the  common  designation  Morbus 
Brightii,  several  separate  diseases  must  be  distinguished  ;  a 
good  natural  classification  is  as  follows : — 

I.  Acute  Bright's  disease — acute  parenchymatous  nephritis. 
II.  Chronic  Bright's  disease. 

(1)  Chronic  parenchymatous  nephritis. 

(2)  Interstitial  nephritis. 

(3)  Amyloid  disease. 

(4)  Mixed  forms. 

The  cases  are  briefly  as  follows : — 

Case    I. — Scarlet  fever — Acute   renal    dropsy — Death. — 

W.  M.,  let.  13.    Admitted  February  9th,   under   Dr.    Ross, 

with  dropsy  and  shortness  of  breath.     Was  healthy  a  year  ago. 

Had  mild  scarlet  fever,  and  some  time  after  it  began  to  have 

severe  headaches,  and  the  feet  became  swollen  in  the  evenings. 

In  November  he  (juit  school,  and  has  been  laid  up  ever  since. 

Dr.  Blackader,  under  whose  care  he  was,  states  that  the  chief 

symptoms  have  been,  up  to  the  date  of  admission,  headaches  and 

dropsy,  which  sometimes  would  become  general.    Urine  has  been 

albuminous,  and  contained  blood  and  casts.    When  admitted  was 

pale,  and  had  oedema  of  feet  and  legs ;  no  fluid  in  abdomen  ;  slight 

dulness,  with  rales  at  right  base.    Urine  scanty,  6  ozs.,  smoky  ; 

sp.  gr.,  1020 ;   contains  much  albumen,  finely  granular  and 

epithelial  casts,  with  blood  cells.     T.,  99.5  ;  P.,  132  ;  R.,  142. 

Ordered  milk  diet,  and  Liq.  Amm.  Ace^  5ii,  with  Inf.  Digital  5ii 


I 


ACUTE    IJRiailT's    DISEASE.  *J 

every  foiM-  hours,  and  a  few  days  after  pilocarpine,  J  of  a  grain, 
which  produced  salivation  and  copious  sweating.  By  the  17th 
the  swelHng  of  the  legs  had  subsided,  but  eyelids  were  puffy  ; 
urnie  clear  and  more  abundant,  50  ozs.  Up  to  the  end  of  the 
montii  patient  varied  :  on  the  22nd  urine  was  again  bloody,  and 
the  loins  were  cupped  ;  pilocarpine  continued  at  intervals.  Early 
in  March  not  so  well.  General  oedema  came  on,  with  great 
oppression  of  breathing.  A  systolic  murmur  has  l)eon  heard  at 
apex  for  a  couple  of  wc-.ks.  IL,t  air  bath  caused  much  restless- 
ness. The  urine  varied  much  ;  was  at  times  very  bloody,  and 
again  clear.  On  the  17th  the  oedema  became  more  intense  ; 
urme  scanty,  14  to  15  ozs.  ;  much  albumen.  Was  taken  home 
on  the  22nd,  and  died  about  the  1st  of  April. 

Ca»k  IL— Mary  C,  set.  8.  Admitted  March  C\  under  Dr. 
Ross,  with  severe  vomiting,  headache  and  slight  swelling  of  feet 
and  legs.  Taken  ill  on  4th,  two  days  before  admission."  Child 
had  scarlet  fever  over  a  year  ago  ;  recovered  completely,  and 
has  been  strong  and  well  since.  Had  mumphs  three  weeks  ago. 
On  above  day  (4th),  had  been  out  and  exposed ;  compIained°of 
boots  being  tight ;  legs  were  found  slightly  swollen.  On  the 
evening  of  the  5th  was  restless,  and  had  headache,  vomitin^, 
and  nose-bleedine;.  ° 

On  admission,  puffiness  of  eyelids,  moderate  oedema  of  feet 
and  legs,  headache  and  vomiting.     Passed  28  ozs.  of  urine  in 
20  hours  ;  dark,  smoky,  large  amount  of  deposit ;  sp.  gr.,  1015  ; 
albumen  abundant.  Microscope  gave  casts,  hyaline  and  epithelial,' 
and  many  free  blood  cells.    Heart  beat  strong  ;  a  soft  bellows 
murmur  in  4th  interspace,  close  to  sternum.    Had  mustard  and 
hnseed  poultices  to  loins.     Next  day  cupped,  and  ordered  Liq. 
Amm.  Acet.  and  Inf  Digital,  an  5ii  every  four  hours.    By  9th, 
vomiting,  nose-bleed  and  headache  had  stopped ;  oedema  less  ; 
urine  more  abundant,  35  ozs.  of  same  characters.     Ordered  hot 
air  bath  every  evening.     By  11th,  mine  Gl  ozs.,  still  dark,  but 
not  so  bloody.     Hot  air  bath  has  acted  very  well.     General 
symptoms  improved.     On  13th,  05  ozs.  of  urine,  smoky,  but  not 
very  dark  ;  contains  less  albumen  ;  very  few  casts ;  ccdcma  gone. 


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8 


SUMMER  8E8SION  CLINICS. 


Temperature,  which  has  ranged  from  100  to  100.5°,  is  now 
normal.  On  18th,  hardly  a  trace  of  albumen,  about  62  oz8. 
daily,  stil!  a  little  smoky  ;  granular  casts.  Hot  air  baths  to  be 
stopped,  also  the  Di^itul.  and  L\t{.  Amm.  Acet.,  and  Basham's 
Mixture  (Tinct.  Ferri  Muri.,  Acetic  Acid  and  Liq.  Amm.  Acct.) 
substituted.  On  night  of  20th,  not  so  well ;  not  so  much  urine, 
40  ozs.,  and  darker ;  many  granular  casts.  Improved  until 
April  9th,  to  which  date  urine  ranged  from  40  to  65  ozs. ; 
sp.  about  1010.  On  April  11th,  urine  again  a  little  reddish 
and  albuminous  ;  child  appears  (juite  well,  but  is  a  little  fever- 
ish. Went  out  on  13th.  A  few  days  ago  she  came  to  report 
herself  as  continuing  well. 

Case  III.*_Jas.  B.,  ret.  23,  a  well-built  labourer.    Admitted 
April  2(Jth,  with  dropsy.    Nothing  of  note  in  family  or  personal 
history.  Has  been  working  on  the  railroad.  One  Sunday,  about 
three  weeks  ago,  he  went  with  some  comrades  to  a  village  seven 
miles  distant  and  drank  heavily.     On  returning  to  the  shanty 
that  night  he  was  unable  to  keep  up  with  his  companions,  and 
lay  down  on  the  snow  for  some  hours,  until  his  friends  returned 
for  him.  The  next  day  he  had  a  slight  chill,  with  pains  in  the  back 
and  in  the  left  side.    These  continued  for  three  or  four  days, 
and  he  then  noticed  that  his  face  was  puffy,  and  the  hands  and 
legs  began  to  swell.     He  does  not  remember  about  the  urine  ; 
thinks  he  passed  as  much  as  usual.     Had  no  vomiting,  no  head- 
ache.    On  admission,  feet  and  legs  oedematous,  the  left  more 
than  the  right ;  face  swollen.     Nothing  spocial  detected  in  ex- 
amination of  heart  and  lungs.     Tongue  coated  ;  appetite  im- 
paired.    Urine— amount  for  first  24  hours  in   which  it  was 
collected,  40  ozs. ;  brownish  red  color,  smoky,  acid  reaction  ; 
sp.  gr.,  1010  ;  contains  a  large  amount  of  albumen,  and  on 
microscopical  examination  presents  red  blood  corpuscles  and 
numerous  casts,  of  which  three  varieties  have  been  detected— 
(a)  hyaline,  with  a  few  scattered  granules ;  (h)  epithelial  casts, 
or  rather  cylinders  with  round  cells,  resembling  leucocytes  ; 
(g)  bloodj^,  composed  chiefly  of  red  blood  corpuscles.    Of 

*  Report  by  Mr.  J.  R.  JoLnsoii.  ~~ 


ACUTE   BRIOIIt's   DISEASE.  9 

these  the  delicate  hyaline  casts  have  been  most  abundant.  For 
four  dajs  we  kept  him  in  bed,  on  a  light  diet,  without  any  special 
treatment,  and  since  that  date  he  has  had  a  couple  of  jalap 
powders  to  keep  the  bowels  loose.  The  oedema  of  the  face  is 
gone,  the  legs  are  less  swollen,  w'.ile  the  amount  of  urine  is 
about  the  normal,  containing  very  little  blood  and  less  albumen  ; 
the  urea,  however,  is  diminished.  The  man  has  been  able  to 
walk  upstairs,  and  has  done  remarkably  well. 

You  will  notice  that  these  three  cases  present  a  striking  uni- 
formity in  the  chief  symptoms— alterations  in  the  character  of 
the  urine,  with  dropsy  ;  hence  the  appropriateness  of  the  old 
term,  Acute  Renal  Dropsy. 

Let  us  now  briefly  review  the  affection,  as  illustrated  by  our 
cases.  ^-Etiologif—lt  is  a  disease  of  early  life  ;  the  great  pro- 
portion of  the  cases  are  in  persons  under  20,  and  as  the  years 
increase,  the  less  frequently  it  is  met  with.  The  case  of  Prof. 
-  ,  who,  nearly  ten  years  ago,  at  the  age  of  about  50, 

had  acute  nephritis,  and  in  whose  continued  good  health  we  now 
rejoice,  is  an  instance  of  the  occurrence  of  this  disease  at  an 
unusually  late  period  of  life.     Scarlet  fever  and  cold  were  the 
causes  which  prevailed  in  our  cases,  and  these  obtain  in  the 
majority  of  individuals  attacked.    It  is  one  of  the  most  dreaded 
sequelae  of  scarlet  fever,  and,  as  in  the  boy  M— ,  not  infrequently 
follows  an  attack  which  is  so  trivial  as  to  be  almost  overlooked. 
Diphtheria  is  an  occasional  cause,  and  the  other  infectious  disease 
may  at  times  be  followed  by  an  acute  inflammation  of  the  kidneys 
After  cold  and  scarlet  fever,  you  will  find,  as  practitioners,  that 
pregnancy  comes  next  in  order  of  frequency  ia  inducing  this 
affection.     How  it  does  so  we  need  not  stop  here  to  inquire,  as 
the  explanations  usually  oftered  are  not  altogether  satisfactory. 

The  morbid  anatomy  has  been  much  discussed.  In  the  early 
stage  we  do  not  often  have  an  opportunity  of  dissecting  the  organs, 
but  doubtless  we  would  find  them  congested  and  swollen.  At 
the  period  in  which  we  commonly  inspect  them— from  three  weeks 
to  three  months  after  the  on^et— the  organs  are  much  enlarged, 
weigh  8  to  10  ozs.,  and  have  the  appearances  known  as  charac- 
teristic of  the  "  large  smooth  kidney,"  or  the  mottled  kidney. 


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SUMMER   SESSION   CLINICS. 


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The  capsule  is  thin,  and  strips  oft' easily  ;  on  section,  the  cortex 
is  seen  to  be  increased  in  thickness  and  anivmic,  or  of  an  opaque 
yellow-white  aspect ;  the  Malpifi;hian  tufts  and  the  arterial  twigs 
are  injected,  as  are  a'so  the  largo  collecting  veins  which  convey 
the  Mood  from  the  stellate  veins  of  the  surface.     The  pyramids 
are  usually  congested,  and  offer  a  striking  contrast  lo  the  pale 
cortex.  The  histological  cli'niges  are  chiefly  in  the  cortical  parts, 
and  consist  in  swel'ing  of  the  epithelium,  which  becomes  more 
granular,  and  may  degenerate  into  a  molecular  debris,  distending 
the  tubules.  Other  tubes  may  cont;iin  blood-cells  and  leucocytes, 
with  casts.      In  later  stages,  fatty  changes  may  cause  patchy 
opacities.   Intertubular  changes,  in  the  form  of  connective  tissue 
proliferation,  have  also  been  described,  and  probably  always  take 
place  in  cases  which  last  several  months.     These  have  been 
specially  described  by  Kleri  in  the  scarlatinal  form.   Bowman's 
capsule  and  the  contained  glomerulus  are  also  involved.     Klebs 
first  called  attention  to  these  changes  (glomerulo-nephritis),  but 
he  believed  them  to  be  entirely  of  the  nature  of  proliferation  of 
the  cells  between  the  capillary  coils.     Probably  the  epithelial 
coating,  as  well  as  capsular  e})ithelium,  is  affected,  i  pass  round 
Langhans  plate  (Virchow's  Archiv.,  Bd.  76),  in  which  these 
changes  are  well  figured. 
^  Syynptoms  —In  the  majority  of  cases  the  appearance  of  oedema 

gives  the  first  indication  to  patient  or  doctor.     In  the  man  B , 

a  slight  chill,  with  feverishness  and  lumbar  pain,  preceded  the 
oedema.  In  case  I,  persistent  headaches  appear  to  have  accom- 
panied the  onset ;  and  in  case  II,  which  followed  cold,  headache 
and  vomiting  were  the  first  symptoms.  The  latter  is  not  infre- 
quent in  the  early  stage  of  scarlatinal  nephritis.  The  most  marked 
feature,  dropsy,  may  vary  from  more  puffiness  of  the  eyelids  and 
oedema  of  the  ankles  to  extensive  general  anasarca,  with  exuda- 
tion into  the  serous  sacs.  The  milder  grade  you  see  in  this  man 
(case  III)  ;  the  more  intense  you  witnessed  in  the  boy  M. 

The  alterations  in  the  urine  are  of  the  utmost  importance.  In 
the  early  stage  it  is  reduced  in  rjuantity,  may  be  only  a  few 
ounces,  or  the  secretion  may  even  be  suppressed.  The  colour 
IS  mcreased,  usually  dark  red,  from  admixture  with  blood  ;  very 


comraonl 

firesence 

duced  ha 

have  had 

disappeai 

specific  (j 

relatively 

normal,  t 

a  copious 

colour,  a 

most  stril 

heat  the  ' 

may  be  p 

is  not  unc 

the  estinii 

apparatus 

30th,  65 

257  grs. : 

The  no 

grs.,  and 

A  materia 

Tube  CI 

their  reco, 

learn  in  cl 

marked  in 

well-forme 

tubules  m; 

matrix.     , 

abundant  i 

experience 

thirdly,  ep 

sisting  of  a 

in  it.     I  c; 

consisting 

corpuscles- 

a  variety  r 

The  var 


ACUTE    BRIOHT's    DISEASE. 


11 


commonly  it  has  a  nmulqj,  lake  colour,  very  characteristic  of  the 
presence  of  bluod,  and  wliich  rosonihlos  a  dihi^.c  sohjtion  of  re- 
duced haemoglobin.     The  various  shades  of  intensity  of  tliis  you 
have  had  an  opportunity  of  seeing  in  case  III.     The  blood  may 
disappear  and  then  recur,  as  it  did  in  cases  I  and  II.     The 
specific  gmvilij  is  increased  at  first,  1020  to  1030,  owing  to  the 
relatively  small  amount  of  water.     When  the  quantity  rises  to 
normal,  the  specific  gravity  is,  as  a  rule,  lowered.    On  standing, 
a  copious  sediment  usually  falls,  reddish  or  reddish-brown  in 
colour,  and  consisting  of  blood  and  urates.     Chemically,  the 
most  striking  change  is  in  the  presence  of  albumen  when  you 
heat  the  urine  in  a  test  tube,  or  add  cold  nitric  acid.    So  much 
may  be  present  that  the  urine  solidifies,  and  50  to  00%  by  bulk 
is  not  uncommon.  The  icrea  is  diminished  in  amount.  In  case  III, 
the  estimates  made  by  Messrs.  Kenner  and  Gooding  with  Duprd's 
apparatus  give  :  28th,  4(J  ozs,  287  grs. ;  29th,  TO^ozs.  403  grs. ; 
80th,  65  ozs.  250  grs. ;  2nd,  (J8  ozs.   228  grs.  ;  ard,  03  ozs. 
257  grs. :  4th,  50  ozs.  247  grs. 

The  normal  amount  for  the  24  hours  is  between  400  and  500 
grs.,  and  an  approach  to  this  or  an  excess  is  a  happy  indication. 
A  material  reduction  is  to  be  feared,  as  urtemia  is  apt  to  follow. 
Tube  casts  furnish  important  evidence  in  this  disease,  and 
their  recognition  is  one  of  the  earliest  lessons  which  you  should 
learn  in  clinical  microscopy.     Their  characters  have  been  well 
marked  in  this  man  (Case  III )     When  first  examined  a  few 
well-formed  blood  cists  were  seen  ;  cylinders  or  moulds  of  the 
tubules  made  up  of  blood  corpuscles  imbedded  in  an  indifferent 
matrix.     H//alme  or  faintli/  yranular   have    been   the   most 
abundant  forms,  very  delicate  and  translucent,  so  that  the  in- 
experienced among  you  have  had  difficulty  in  seeing  them  ;  and 
thirdly,  epithelial  casts,  not  very  numerous,  but  commonly  con- 
sisting of  a  hyaline  cylinder,  with  a  few  granular  cells  imbedded 
in  it.     I  called  the  attention  of  some  of  you  to  a  form  of  cast 
consisting  almost  entirely  of  rounded  cells,  like  colourless  blood' 
corpuscles— leucocytes  ;  this,  Dr.  George  Johnson  believes,  is 
a  variety  met  with  when  a  glomerulo-nephritis  is  present. 
The  varied  course  of  the  disease  is  well  illustrated  by  the  first 


I . 


Pi,! 


Hi 


?jr 


i 


ri  m 


l''s  M 


I 


12 


SUMMER   SESSION   CLINICS. 


two  casea,  one  cf  which  went  from  bail  to  worse,  wliile  the  other 
rapidly  improved.     The  first  six  months  in  the  majority  of 
instances  concludes  the  case  one  way  or  the  other.     Not  that 
recovery  is  imp'>ssible  after  this  date,  hut  it  is  more  nnocrtain, 
and  the  possibility  is  great  of  permanent  damage  to  the  organs 
and  of  the  establishment  of  chronic  parenchymatous  nephritis. 
The  favourable  signs  are  diminution  and  disappearance  of  the 
dropsy,  increase   in   the  amount  of  urine,  with   reduction  in 
albumen  and  maintenance  of  normal  urea  excretion.     In  the 
most  rapid  cases  three  or  four  weeks  at  least  are  'locessary  before 
the  condition  of  the  urine  becomes  normal.     I  nave  kno\\  n  the 
albumen  to  disappear,  while  the  tube  casts  continued.    Circum- 
stances which  warrant  unfavourable  prognosis  arc  long  duration, 
persistence  of  the  albumen  in  large  amount,  material  reduction 
in  urea  and  the  onset  of  symptoms  of  uricmia,  some  of  which  are 
sudden  and  rapidly  fatal. 

What  are  the  indications  for  treatment ':'     Mild  cases  would 
probably  recover,  indeed,  have  done  so,  left  to  nature.    Case  III 
received  no  special  treatment  for  four  days,  and  improved  durin" 
this  time.     The  rest  in  bed,  recumbency  and  the  quiet  do  much, 
but  there  are  few  cases  which  do  not  call  for  active  interference. 
In  the  early  stages,  where  the  congestion  of  the  organs  is  marked, 
the  urine  reduced  in  amount  and  bloody  and   the   lumbar  pain 
present,  dry  cupping  the  loins  and  warm  fomentations  do  much 
good,  acting  as  derivatives.     You  know  on  general   principles 
that  the  first  thing  to  be  done  with   >  i  ..cutely  inflamed  organ  or 
part,  is  to  give  it,  if  possible,  func    ki     rest.    With  the  kidneys 
this  is  impracticable,  but  we  can  relieve  and  assist  them  in 
various  ways.    A  spare  diet  and  rest  diminish  the  amount  of 
solid  materials  to  be  excreted.    Purgatives  and  diaphoretics  call 
to  aid  the  bowels  and  skin,  which  supplement  the  action  of  the 
kidneys,  and,  as  it  were,  help  them  in  a  friendly  way  when  they 
are  disabled.    In  the  early  stages  and  in  mild  cases,  there  is  no 
necessity  for  severe  purgation.  Keep  them  loose  by  a  daily  dose 
of  Glauber's  Salts  (Soda  Sulph.  5ss),  and  perhaps  an  occa- 
sional Jalap  purge  (Pulv.  Jalapjie  co.  5ss).   In  the  more  chronic 
cases,  where  the  dropsy  is  great  and  uraemia  threatening,  hydra- 


ACUTE    imHllIT.S    DISEASE, 


13 


l\ 


}!,'>'A^\<i  cathartii's  will  bo  of  i;reat  service.  Of  iliaphoretics,  the 
Olio  in  oominoii  iiso  and  most  ctficacioiis?  is  juborandi,  or  ita 
active  principle,  i>tlu<-nr/nn  ;  of  the  former  raay  bo  given  n^x  of 
the  Fl.  Ext.  ovory  two  hours  until  copious  sweating  is  induced  ; 
of  the  latter  a  hypoderniic  injection  of  ,',  to  \  gr.  But  of  all 
measures  at  our  disposal  to  j)roduco  sweating,  the  hot  air  both 
h  in  my  exp.rience,  the  b  -.,  \\h;  easiest  employed,  and  has  the 
additional  advantage  of  be  ng  in  mui  /  instances  a  diuretic,  so 
that  after  a  most  cojuous  swii  in<?;  tbr  amount  of  urine  for  the 
12  or  1(3  hours  subsequen.  u;-;' '  o  actually  increased.  On 
our  return  to  the  ward  wc  sha  ,  give  our  patient  B.  such  a  bath 
that  you  may  sec  the  ease  with  which  it  is  applied.  Some  of  you 
may  remember  two  sessions  ago  the  case  of  a  little  girl  in  the 
children's  ward  with  acute  renal  dropsy,  and  how  admirably  the 
air  baths  acted  with  her  without  any  medication.  The  warm 
baths  are  much  used  in  some  hospitals,  but  they  are  inconvenient. 
The  wet  pack,  wrapping  in  a  wet  sheet  and  rolling  in  blankets 
is  unpleasant  for  the  patient,  and  has  no  special  advantage. 
What  about  diuretics  ?  In  the  early  stage,  with  active  conges- 
tion and  bloody  urine  ;  no,  but  later  they  raay  be  advantageously 
employed,  and  good  fresh  water  may  be  taken  freely  and  often 
answers  the  purpose.  It  is  of  importance  to  keep  up  the  amount 
of  urine  for  two  reasons  :  first,  the  larger  the  (juantity  the  more 
solid  matter  will  bo  removed  ;  and,  second,  the  tubuU  urhiiferi 
are  thereby  flushed  (Dickenson),  the  dcbrin  washed  out,  and 
chokhu/  of  the  renal  drains  is  in  this  way  i)re  vented.  If  a  special 
diuretic  is  indicated,  the  Inf.  Digitalis,  as  used  in  cases  I  and  II, 
may  be  given.  The  diot  should  be  light  and  nutritious  ;  not 
much  meat.  Milk  is  much  used  in  these  cases,  and  the  diet 
may  be  restricted  to  it  as  in  case  I. 


1 ' 

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14 


6UMMEK   SESSION   CLINICS. 


Nos.  III.  and  IV. 

PNEUMONIA.^ 


f 


Gentlemen,— The  commoner  diseases  which  you  study  in  the 
wards  often  do  not  attract  the  attention  which  they  deserve. 
Students  too  frequently  look  out  for  the  rare,  less  common,  but 
to  them  more  interesting,  forms  of  disease,  to  the  neglect  of  those 
which  they  are  more  liable  to  meet  with  in  private  practice, 
and  of  those  which  it  is  important  for  them  to  know  thoroughly 
and  accurately.     Among  affections  which  it  is  of  paramount 
importance  for  you  to  thoroughly  know,  pneumonia  perhaps 
heads  the  list.      There    is    no    acute   affection   of  the   same 
importance   so  often  met  within  this  country.      So  frequent 
is  it,  that  from  5  to  G  per  cent,  of  fatal  cases  of  disease  arc  attri- 
butable to  this  cause.     In  this  hospital  you  have  opportunities 
of  studying  It  in  all  its  varieties.    The  four  cases  which  you  have 
been  following  in  ward  11  shall  serve  as  my  text  for  the  next 
two  lectures,  and  I  will  first  read  to  you  brief  notes. 

Case  Lf— Louis  Phillippe,  xt  58,  labourer,  admitted  April 
loth  with  cough  and  pain  in  the  side.  Chill  Kve  days  before 
admission.  Temperature  lOFF. ;  pulse  10(3 ;  respirations  20 
Expectoration  not  bloody,  Phj.ical  signs  of  pneumonia  over 
right  lower  mammary,  infra-axillary,  scapular,  and  infra-scapu- 
lar regions.  During  the  first  ten  days  in  Hospital  patient 
made  no  satisfactory  progress  ;  temperature  ranged  from  90°  to 

}^To'.  ^^7";'  ^'""'^  ^"^  '^'"'  "'^  '^^'"-'^"^  5  pulse  weak,  100 
to  1.0.     Ordered  whiskey  5  x  and  supporting  diet,  with  Li., 
Am.  Acet.  and  Ammon.  Carb.     On  23rd,  defective  resonance 
in  infra-clavicuIar  regions  on  right  side ;  in  mammary  region 
aJaU^amtic^te.     Behind,  absolute  dulness,  feeble  blow- 

•  stenographic!  report  by  James  Cranksh^,^s77^I 
t  Reported  by  B.  J.  Harrison,  B.A.  " 


ing  breathi 
note  over 
emaciating 
muco-puru 
temperatui 
Died  at  mi 
Autopay 
colour;  a  f 
fibroid  chai 

Case  XL 
had  pneum 
by  fever,  o 
quite  deliri 
86.  Physi 
angle  of  sci 
regions.  1 
above  angl( 
was  at  once 
until  (juietc 
been  attenc 
which  he  a] 
tinned  delii 
1»9°  to  102' 
grs.  v.  ever 
when  need 
signs  not  m 
On  28th,  V 
purulent  an 
with  blood. 

On  the  A 
Temperatui 
is  a  loud  cr 
very  distin( 
To-day  (12i 
cough  less  i 
is  clearing. 

•  Reported 


PNEUMONIA. 


15 


ing  breathing  ;  a  few  rales  on  ilccp  inspiration.  On  the  29tli,  the 
note  over  right  mammary  was  markedly  tympanitic.  Patient 
emaciating.  No  heart  murmur  ;  very  little  expectoration, 
rauco-purulent,  not  bloody.  On  the  0th  he  had  a  chill,  and  the 
temperature  went  up  to  104''.  No  change  in  physical  signs. 
Died  at  mid-day  on  the  10th. 

AutopHi/  showed  uniform  solidification  of  right  lung,  grey  in 
colour;  a  few  purulent  depots,  and  several  areas  of  commencing 
fibroid  change. 

Case  II.*— W.  R.,  ajt.  43,  admitted  April  loth ;  said  to  have 
had  pneumonia  for  ten  days.  History  of  a  distinct  aill,  fallowed 
by  fever,  cough  and  pain  in  the  right  side.  When  admitted  was 
quite  delirious.  Temperature  lOl^F.  ;  pulse  92  ;  respirations 
36.  Physical  signs  confined  to  right  lung  ;  dulness  as  low  as 
angle  of  scapula  and  extending  round  in  axillary  and  mammary 
regions.  Feeble-blowing  breathing  and  riiles  ;  a  loud  friction 
above  angle  of  scapula.  Cough  slight,  no  expectoration.  He 
was  at  once  put  on  brandy,  and  had  5s3  doses  of  Potas.  Bromid. 
until  quieter.  We  learnt  that  this  man,  some  months  ago,  had 
been  attended  by  Dr.  Kennedy  for  trouble  at  right  apex,  from 
which  he  appeared  to  have  recovered.  Up  to  the  20th  he  con- 
tinued delirious  and  very  noisy  at  night.  Temperature  not  high, 
1»9°  to  102°.  Has  been  on  whiskey  12  ozs.  and  Ammon.  Carb. 
grs.  v.  every  six  hours,  and  the  Potas.  Bromid.,  with  Chloral, 
when  needful.  Expectorauon  purulent.  On  22nd,  physical 
signs  not  mucli  changed  ;  dulness  marked  in  infra-scapular  area. 
On  28th,  very  slight  fever  ;  cough  troublesome  ;  expectoration 
purulent  and  more  profuse,  a  little  foetid,  occasionally  streaked 
with  blood.     Note  is  clearer  behind  ;   rales  still  numerous. 

On  the  4th  the  note  reads :  Still  a  little  delirious  at  times. 
Temperature  101°.  Lung  has  cleared  somewhat  in  front ;  there 
is  a  loud  creaking-sound  friction  above  the  nipple.  Heart  sounds 
very  distinct  on  this  side ;  behind,  still  dull  in  upper  regions. 
To-day  (12th)  he  is  much  better  ;  no  fever  ;  appetite  improving  ; 
cough  less  frequent ;  expectoration  muco-purulent,  and  the  lung 
is  clearing. 


I     ' 


ti 


I    H 


F  ; 


*  Reported  by  Mr.  C.  B.  H.  Hanvey. 


|i^  !' 


16 


SUMMER  SESSION   CLINICS. 


Case  III.*- J.  W.  C,  xt.  20,  admitted  April  24th  with  con- 
sulidation  of  the  greater  part  of  the  left  lung.     Has  been  a 
healthy  young  man.     Sixteen  days  before  admission,  was  taken 
with  pain  in  chest  and  shortness  of  breath,  and  was  in  bed  a 
week.     Some  doubt  as  to  the  nature  of  this  attack.     Went  out 
on  the  18th,  but  next  day  had  to  go  to  bed,  where  he  has  been 
ever  since,  with  fever  and  cough.    He  had  no  chill.    On  exami- 
nation, very  slight  movement  of  left  chest ;  tender  on  pressure 
about  left  nipple,  and  he  feels  pain  here  on  drawing  a  full  breath. 
Tactile  fremitus  is  less  marked  on  this  side.     Percussion  gives 
a  flat  note  from  level  of  3rd  rib  in  front  and  over  the  left  back, 
except  supra-scapular  region.     Blowing  breathing  over  the  dull 
areas,  with  a  few  fine  rides.    Vocal  fremitus  ina-eased.     Expec- 
toration tenacious,  muco-purulent,  a  little  rusty.     Temperature 
102° ;  respirations  64 ;  pu.so  108.     Ordered  poultices  to  the 
chest,  and  Liq.  Ammon.  Acetat.  5ss  every  three  hours.     On 
the  26th,  temperature  101" ;  respirations  48  ;  pulse  104  •  feels 
nmch  better.     29th-Has  continued  to  improve  ;  temperature 
J8   ;  pulse  92 ;  respirations  28.     Note  is  clearer  in  front  •  no 
change  behind.     Tactile  fremitus  continues  weak  on  this  'side 
compared  with  the  opposite.     Takes  food  well.     Since  this  date 
he  has  done  well,  and  is  now  (12th)  without  fever,  and  the  lung 
is  clearing  rapicJly.  ^ 

Case  IV.f-M.  B.,  aet.  35,  admitted  May  8th.  Has  been  a 
healthy  man,  and  looks  of  ,iood  constitution.  Four  days  a-^o  was 
at  work  and  well.  On  the  i,ight  of  the  4th  was  awakened  by  a 
severe  dartmg  pain  in  the  ri^dit  side ;  felt  feverish  ;  had  no  chill  • 
but  m  the  morning  felt  very  ill,  and  began  to  cough  and  .et' 
short  of  bre.un.  These  symptoms  have  continued.  When  ad- 
mitted  temperature  103°  ;  pulse  104 ;  respirations  29.     Face 

on  fl  ■.  pT''.'"'  "^''^  '^''"  ^''"^'^  '  «'^P^"^'«»  greatest 
on  left  side.  Palpation  gives  increased  tactile  fremitus  over  the 
righ   lung.     Percussion  on  right  side  clear  in  front  as  low  as 

*  Reported  by  Mr.  C.  J.  B.  Hanvey. 
t  Report  by  Mr.  H.  J.  Harrisson,  B.A. 


v^ 


1^. 


PNEUMONIA. 


17 


mfra-scapu  ar  areas,  there  is  a  flat,  tympanitic  note.  Ausculta- 
t.on_over  these  parts  ,ives  blowin.-b.eathin,,  with  fine  rAle  o . 
.nsp,rat.on;  vocal  fremitus  much  increased.  Ordered  Li,  Am 
Acetat.  and  hght  nourishing  diet;  no  poultices.  To-day  1-^th) 
temperature  .  98°  ;  pulse  76;  respirations  22.  Sput'm Very 
tenacious  and  rusty,  is  expectorated  witii  difficulty.  IIo  has 
done  well,  and  in  a  few  days  will  be  convalescent. 

Now,  the  first  question  to  ask  with  reference  to  pneumonia  is, 
what  .  ,t?     A  local  inflammation?  or,  a  specific,  essential 
fever  ?     Is  ,t  simply  a  local  trouble  in  the  lung,  and  the  con- 
stitutional disturbance,  the  fever,  caused  by  that  ?  or  is  it  a 
spec.ficfever,  like  typhoid,  of  which  the  local  lesion  is  the'special 
expression  ;  just  as  tl.o  lesion  in  typhoid  fever  is  the  special  ex- 
pressionof  a  constitutional  disorder  ?     The  opinion  is  .minin.r 
ground  in  the  profession,  particularly  on  this  continent  and  in 
(^ermany,  that  it  is  in  reality  a  specific  essential  fever.    Amon- 
the  grounds  which  are  supposed  to  favour  this  are  its  occasional 
occurrence  in  epidemic  form.     Epidemics  of  pneumonia   have 
been  recorded  in  the  last  century,  and  even  in  previous  centuries  • 
and  a  recent  epidemic  has  been  reported  in  Germany.  The  lesion 
cannot  be  produced  experimentally.     You  cannot  get  ordinary 
pneumonia  by  any  methods  of  experimentation.     You  can  -et  a 
catarrhal  affection  but  fibrinous  or  croupous  pneumonia  cannot 
be  produced  by  local  irritation,  or  causinjr  animals  to  inhale  hot 
au-  or  other  such  methods.  The  remarkably  uniform  course,  and 
he  absence  of  any  positive  relationship  between  the  extent  of 
es.on  and  the  constitutional  symptoms  also  point  in  this  direc- 
tion.    Cohnhe.m  and  some  other  German  writers  class  it  with 
the  miasmatic  contagious  affections.     For  good  articles  bearing, 
on  this  .juestion  let  me  refer  you  to  Dr.  Sanders'  papers  in 
fc^eguin  s  Archiv.  for  June  and  August  of  last  year 

With  reference  to  the  etiolo>j^  of  the  disease,  the  most  im- 
portant points  are  as  follows :  It  is  an  affection  which  attacks 
all  ages-from  infants  to  persons  in  advanced  life.  The  maiority 
of  cases  occur,  however,  in  the  middle  periods  of  life,  and  males 
are  more  frcjuently  affected  than  females.     Of  85a  cases  of 

B 


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18 


SUMMER    SESSION    CLINICS. 


pneumonia  witliiu  ten  years  in  this  hospital,  2C)l)  were  males  and 
88  females.  Of  00  autopsies  of  which  I  have  records,  only 
two  wore  in  children  under  2  years  old.  The  great  majority 
were  in  adults  from  the  ages  of  25  to  45.  Though  healthy, 
robust  persons  are  affected,  it  is  specially  prone  to  attack 
debilitated  individuals  in  a  community,  and  persons  already 
affected  with  some  disease.  Season  would  appear  to  have  a  great 
influence  on  this  affection.  The  months  in  which  we  have  the 
largest  number  of  cases  are  March,  April  and  May.  Next  are  the 
autumn  months,  or  rather  the  early  winter  months,  November 
and  December.  During  the  full  winter  time,  January  and 
February,  the  cases  arc  not  so  numerous,  though  they  are  more 
numerous  than  in  the  summer  months,  the  time  when  such  cases 
are  fewest  in  number.  These  are  facts  based  on  the  853 
cases  of  pneumonia  admitted  into  the  hospital,  as  contained 
in  the  statistical  report  of  Dr.  Bell.*  It  varies  in  different 
years.  We  have  not  as  many  this  year  as  last  year  ;  and 
last  year  we  had  not  as  many  as  the  ycpr  before.  You  will 
notice  from  this  that  it  would  not  appear  to  L  in  the  coldest 
months  that  we  get  the  greatest  number  of  case.  ■)f  pneumonia, 
but  in  those  months  in  which  the  variations  of  'emperaturc  arc 
marked. 

Next,  as  to  the  morhid  anatomy  oi  the  affection.  The  term 
lobar  is  frerpiently  applied  to  this  form  of  disease  in  contradis- 
tion  to  lobular.  In  this  form  of  pneumonia  the  rule  is  for  cither 
a  considerable  portion  of  a  lobe,  an  entire  lobe,  or  the  whole  lung 
to  be  involved  in  the  disease.  You  rarely  find  a  pneumonia  less 
in  extent  than  the  area  of  the  palm  of  tho  hand.  The  lower 
lobes  of  the  lung  are  more  frequently  involved  than  the  upper 
lobes.  The  right  lung  is  more  frorpicntly  involved  than  the  left. 
In  the  60  autopsies  to  which  I  have  referred,  40  occurred  in 
the  right  lung  and  20  in  the  left.  An  exception  tV  rule, 
which  states  that  it  is  most  frequent  in  the  lowc.  lo.^eo  '3  the 
pneumonia  of  old  people  and  of  drunkards.  In  '■b'^se  it  most 
frequently  involves  the  upper  portion  of  the  lung  ;  hence  the 


'  Montreal  General  Hospital  Reports,  Vol.  I,  1880. 


¥« 


PNEUMONIA. 


19 


tcnn  apex   pneumonia.     And  this  variety  sometimes  presents 
special  clmioal  features,  which  are  of  great  importance. 

The  stages  of  the  disease  are  as  follows.     They  are  usually 
spoken  of  as  four  in  number  : 

(1)  The  stage  of  engorgement. 

(2)  The  stage  of  red  hepatisation. 

(3)  The  stage  of  grey  hepatisation. 

(4)  The  stage  of  resolution. 

We  rarely  have  opportunities  of  seeing  a  lung  in  the  sta^^e  of 
engorgement;  but  we  can  sometimes  gather  what  the  condition 
IS  from  a  death  which  takes  place  early  in  the  di^oase.    A  very 
favourable  instance  for  the  observation  of  this  occurred  a  few 
years  ago,  owing  to  an  unfortunate  accident  by  which  a  patient 
too.<  two  drachms  of  solid  morphia  instead  of  two  dracliras  of  the 
Liquor  Morphine.     This  patient  died  in  the  course  of  12  or  14 
hours,  and  at  the  autopsy  we  found  that  there  was  a  commencin-^ 
pneumonia  in  the  lower  lobe  of  the  right  lung.     This  part  was 
heavy,  feebly  crepitant,  contained  much  blood,  and  portions  ex- 
cised from  the  superficial  part  floated,  but  in  the  central  portion 
m  four  or  five  isolated  areas,  about  the  size  of  marbles,  the  lun-^ 
was  firm,  and  had  the  usual  appear. .  ,o  of  red  hepatisation,  and 
no  doubt  represented  the  commencement  of  solidification  ;  if  he 
had  lived  another  24  hours,  he  would  doubtless  have  had  uniform 
hepatisation  of  the  lung.     In  the  stage  of  red  hepatization,  the 
characters  of  the  Inng  are  exceedingly  well  marked.     We  have 
had  throe  autopsies  this  week  on  cases  of  pneumonia  ;  and  I  have 
reserved  for  this  lecture  two  specimens,  showing  the  condition 
of  the  lung  in  the  second  stage.     On  inspection,  the  first  thin- 
you  notice  is  that  the  surface  of  the  pleura  over  the  affected 
part  has  lost  its  glistening  appearance  ;  it  is  turbid  and  lustre- 
loss,  or,  as  you  sec  in  the  second  specimen  here,  it  i^  covered 
AVith  a  distinct  layer  of  lymph.  Now,  my  experience  is  that  this 
superficial  pleuritis  is  a  constant  feature  in  pneumonia;  so  soon 
as  the  inflammation  reaches  the  pulmonary  surface,  it  of  neces 
s.ty  involves  the  pleura.     You  may  have,  as  you  see  in  this 
hrsc  lung,  only  turbidity  of  the  pleural  surface.  You  may  have 
as  you  see  here,  in  this  second  one,  a  thin  sheeting  of  fibrin  ' 


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20 


SIIMMEH    SESSION    CLINICS. 


but  you  also  may  liiive  a  layer  of  fibrinous  exudation  liom  half 
an  inch  to  au  inch  aiid  a  quarter  in  thickness.    I'.'Mo  one  spoci- 
mcn  which  shews  ;^encral  hepatization  of  the  iung,  unu  a  unitbrm 
sheeting  of  exudation  over  nn  inch  in  thickness,  extei\  ling  from 
apex  to  base.     Secondly,  the  lung  in  red  hepatization  does  not 
collapse  ;  it  is  full  in  volucie.     Thii'd,  !o  the  touch  it  is  firm  and 
nowhere  crepitant.     There  is  a  solidity  abo''t  it  resnmbling  one 
of  the  solid  or',rans,  as  the  i'/er — hencfj  the  appropriateness  of 
the  term  hepatization.     Indeed,  with  the  eyes  dosed  y<.'U  cou-d 
not  U'll  by  touch  a  portion  of  liver  from  a  portion  of  ho^.atized 
lung.    h.  lifis  lost  the  crepitant  feel  of  healthy  lung.  On  section, 
the  api^carariOe  is  the  following: — The  surface  is  of  a  uniform 
roddir^li  'i!  li   ti.e  color  varying  very  much  ;  in  (lie  early  stage 
a  bright  red,  in  the  later  stages  a  dusky  red,  a  ^  you  see  hero 
in  this  specimen.    Not  much  fluid  bathes  the  section.    On  close 
inspectioii,  you  can  see  that  the  surface  presents  numerous  small 
fine  granules,  whicli  are  very  characteristic  of  this'  stage  of  the 
disease,  and  which  consist  of  fibrinous  plugs  filling  the  air-cells. 
Usually  they  are  not  of  the  same  intense  red  as  tlio  alveolar 
walls,  and  can  be  seen  in  contrast  to  the  portions  about  them, 
though  in  the  early  stage  these  fibrinous  plugs  may  be  just  as 
red  as  the  surrounding  parts.    The  lung  is  friable — breaks  very 
easily.     This  is  in   marked  contrast  to  healthy  lung.     Try  to 
tear  a  portion  of  liealthy  lung  ;  it  is  done  with  great  difficulty, 
and  you  cannot  easily  put  your  finger  into  it ;  but  with  a  bit  of 
pneumonic  lung  you  can  put  your  finger  in  with   the  greatest 
ease,  and  it  breaks  with  an  irregular  fracture.     The  bronchi, 
more  particularly  the  smaller  ones,  often  contain  fibrinous  plugs, 
the  consistence  of  which  varies  much,  some  being  simply  muco- 
purulent, others  being  distinctly  fibrinous  and  firm.     The  pul- 
monary vessels  are  occasionally  thrombosed. 

In  the  third  stage  of  the  disease  the  picture  is  considerably 
modified,  more  particularly  as  regards  the  colou'  '  the  lun<^, 
which  is  changed  from  a  reddish  to  a  greyish  yell  .  greyish- 
white.  The  ''<"■:  ion  is  no  longer  dry,  but  a  'sid'  .  Ae  (juantity 
of  purulent  n:  ::<■•  r  bathes  the  surface,  or  can  '  ,;.  •  ozed  from  it 
and  this  matter  looks  just  like  as  if  it  came  inr.  ■  >  fresh  abscess. 


4i  <'' 


PNEUMONIA. 


21 


In  this  portion  of  the  lung  of  the  sccon.l  specimen,  you  see  it 
passmg  to  the  stage  of  grey  hepatisation  ;  an.l  you  see  here,  on 
the  knife,  the  purulent  substance,  which  can  be  scraped  from  it 
Ihis  grey  colour  is  due  to  two  cause..     Li  the  first  place,  there 
IS  much  less  blood  in   the  lung,  owing  to  compression  of  the 
alveolar  walls  by  an  increase  of  the  contained  cell  elements ;  and 
secondly,  the  colouring  matter  of  the  blood-corpuscles  exuded 
into   the  air-cells  in  the  stage  of  red  hepatisation  under.^oes 
changes  and   gradually   becomes   dissolved.      In  this  portion 
you  see  that  grey  hepatisation  is  in  the  early  sra-^e     There 
IS  not  much  infiltration  of  the  lung.     In  the  late  stage  of  .rev 
hepatisation  you  may  have  the  lung  so  infiltrated  with  puslhat 
the  term  pundent  injiltration  has  been  well  applied  to  it      It 
looks  saturated  with  or  soaked  in  pus.  There  is  the  same  friability 
about  the  grey  hepatisation  as  about  the  red,  and  the  chan-^es 
of  the  bronchi  and  pleura  remain  the  same,  ° 

Before  speaking  of  the  stage  of  resolution,  it  will  be  better  to 
speak  of  the  histology  of  the  process,  and  the  followin.^  briefly 
are  the  chief  facts  known  with  reference  to  it.     In  the  sta-'e  of 
engorgement  the  blood-vessels  are  distended,  particularly  the 
capillaries  of  the  alveoli ;  the  epithelium  of  the  air-cells  is  more 
granular  ;  and  some  describe  a  nuclear  proliferation,  an  increase 
m  the  cells.     In  the  second  stage-red  hepatisation-there  is 
an  exudation  from  the  blood-vessels  into  the  air-cells  consisting 
of  fibrine,  red  blood  corpuscles  and  colourless  blood  corpuscles 
and  mixed  with  these  are  the  products  of  proliferation  of  the' 
epithelium  of  the  air-cells.     The  fibrine  coagulates,  and  the  cells 
are  entangled  in  its  meshes,  as  you  see  in  this  plate  taken  froL 
Delafield's  "  Pathological  Studies."     The  number  of  red-blood 
corpuscles  within  the  air-cells  is  very  considerable,  as  you  will 
see  in  the  specimens  I  will  shew  you  afterwards  with  the  micro- 
scope.    In  the  stage  of  grey  hepatisation,  the  chief  change  is  an 
enormous  increase  in  the  number  of  leucocytes.     Each  air-cell 
appears  to  be  distended  with  a  plug  composed  of  closely-packed 
colourless  elements.     The  fibrine  fibres  are  much  less  distinct, 
and  the  red-blood  cells  are  no  longer  to  be  discovered.  In  many 
of  the  cells  fatty  degeneration  can  be  seen,  particularly  in  the 


...    ,  -jp.  ,      .  . .  f      '.a 


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22 


SUMMER  SESSION   CLINICS. 


\     % 


lar<^or  ones,  which  results  from  epithelial  proliferation.  These 
changes  are  well  shewn  in  this  plate  from  Dr.  Delafield's  work. 
The  tissues  of  the  air-colls  undergo  little  or  no  change,  with 
the  exception  of  the  epithelial  lininp^.  With  regard  to  the 
stage  of /vso/x^io;/ — the  terminal  stage  of  pneumonia — that  in 
which  the  lung  is  restored  to  the  normal  condition,  we  still  lack 
satisfactory  evidence  of  the  precise  nature  of  these  changes. 
The  elements  within  the  air-cells  undergo  fatty  degeneration. 
This  we  can  see  in  the  ordinary  gray  hepatisation.  This  is,  in 
reality,  the  essential  change.  By  this  the  cells  are  dissolved, 
liquified,  and  the  emulsified  matter  is  either  absorbed  or  it  is 
thrown  out  in  the  expectoration.  It  takes  some  timo  for  a  lung 
to  undergo  complete  resolution,  several  weeks  in  all  probability, 
and  usually,  when  a  patient  leaves  the  hospital,  and  is  appa- 
rently quite  well,  you  will,  on  careful  observation,  ascertain  some 
slight  changes  in  the  affected  region  of  the  lung. 

A  word  with  reference  to  the  amount  of  solid  exudation  which 
may  occur  into  the  lung  in  pneumonia.  This  may  sometimes 
amount  to  several  pounds.  One  lung — the  healthy  lung — may 
weigh  a  pound  or  a  pound  and  a  quarter,  and  the  other  lung 
may  weigh  three  or  four  pounds.  There  may  be  2^  to  3  pounds 
of  solid  exudation  in  the  lung  affected.  In  the  GO  cases  of 
pneumonia  referred  to,  the  heaviest  lungs  that  I  met  with 
were  two,  one  of  which  weighed  over  2,800  grammes,  and  the 
other  2,200. 

Unfortunately,  the  termination  by  resolution  is  not  the  only 
one  which  maj^  go  on  in  pneumonia.  .The  following  changes 
may  occur,  though  they  arc  rarely  met  with  :  In  the  first  place, 
in  the  stage  of  gray  hepatisation  there  may  be  the  formation  of 
an  abscess.  The  purulent  infiltration  may  be  so  intense,  may 
infiltrate  the  parenchyma  of  the  lung  to  such  a  degree,  that  in 
certain  localized  areas  the  tissue  breaks,  with  the  result  of  form- 
ing small  pockets  of  pus.  Now,  this  is  an  exceedingly  rare 
termination.  In  these  GO  cases,  only  three  presented  small  ab- 
scesses which  were  formed  in  this  way.  Cases  32  and  35  both 
presented  small  purulent  foci.  In  one  of  them,  two  of  the 
pockets  were  as  large  as  walnuts,  and  in  the  other  they  were  the 


PNEUMONIA. 


23 


size  of  marbles.     Tins  unfortunate  termination  in  pneumonia  is 
most  frequent  in  old  or  debilitated  people. 

Gangrene  is  a  second  and  still  more  untoward  event  In  this 
set  of  autopsies  there  were  two  cases  in  which  a  fatal  termination 
was  md.iced  by  gangrene.  One  of  these  many  of  you  had  an 
ojiportumty  of  seeing  last  year  under  the  care  of  Dr  Ross 
Dunng  the  wmter  session  a  patient  was  admitted  with  pneumonia, 
a  very  debilitated  woman,  and  death  occurred  within  a  week 
from  gangrene.  There  was  a  gangrenous  mass  at  the  upper 
part  of  the  lower  lobe,  and  the  remainder  of  the  lun-  was  in 
the  condition  of  red  hepatisation  This  may  come  on  in  the 
stage  of  red  hepatisation,  and  may  be  due  simply  to  the  inten- 
sity of  the  inflammation,  but  more  commonly,  it  is  thought,  to 
the  blocking  of  the  pulmonary  arteries. 

Whether  the  exudation  of  lobar  pneumonia  in  a  healthy  man 
ever  undergoes  caseation  or  transformation  into  cheesy  matter 
13  still  much  disputed.     Niemeyer  and  several  other  German 
writers  think  it  may.     Professor  Buhl,  of  Munich,  holds  that  in 
any  case  in  which  a  caseous  degeneration  is  discovered  post- 
mortem  though  there  may  bo  no  doubt  about  the  caseous  nature 
of  the  change,  there  is  much  doubt  of  accuracy  of  dia-mosis    In 
only  one  instance  in  the  past  six  years  have  I  met  wiUi  a  case 
that  appeared  to  justify  a  belief  in  the  transformation  of  the  in- 
flammatory products  of  lobar  pneumonia  into  these  cheesy  sub- 
stances.   The  case  is  recorded  in  my  first  pathological  report. 

The  last  and  rarest  of  all  the  modes  of  termination  of  lobar 
pneumonia  is  the  non-resolution  of  the  exudation,  the  persistence 
of  the  process,  and  the  gradual  onset  of  fibroid  chan-e  in  the 
lung   (chronic  or  interstitial  pneumonia.)     Now,  in'^the   case 
of  the  man  Phillippe,  who  was   under  our  examination  here 
for  nearly  three  weeks,  and  who  died  the  day  before  yester- 
day, this  change  was  beginning.     His  right  lung,  us  you  see 
here,  was  uniformly  solid,  greyish  in  color,  with  recent  pleu- 
ritic exudation,  and  the  surflice,  on  section,  bathed  with  serous 
fluid.     On  ci..:,  lully  inspecting  the  cut  section,  three  features 
call  for  attrition.     In  the  first  place,  in  certain  regions  you 
can  still  see  the  air-cells  with  their  fibrinous  plugs,  of  a  very 


w 


tw. 


i  I 


24 


?l>rMEU    8EHSI0N   CLINICS. 


opaiiuo  v.'-lh  oimr.'n./  undergoing  fatty  clian^'o.  Those  arc  to 
bo  seen  ovor  tonsideralilo  areas.  Secondly,  there  are  small 
pocketH  if  pus,  localized  areas  densely  infiltrated  with  pus,  and 
breaking  down  into  definite  abcesses.  The  largest  of  these  is 
about  tlio  size  of  a  inarl)lc.  And  thirdly,  in  several  areas  of  the 
lung  there  arc  spots  which  !  ^    '.ranslucent  aspect,  are 

firm,  smooth,  homogeneous,  not  granular,  and  have  the  look  of 
a  recent  connective  tissue.  These  are  spots  of  special  interest 
to  us,  because  in  these  areas  a  fibroid  change  is  goin'»  on  in 
the  lung ;  and,  as  you  will  see  in  the  specimen  under  the 
microscope,  the  alveolar  walls  are  infiltrated  with  fibrous  elements, 
and  actually  the  fibrin- us  plugs  themselves  filling  the  air-cells 
are  represented  by  and  transformed  into  a  new  growth  of  con- 
nective tissue.  This  is  an  exceedingly  rare  method  of  termina- 
tion. It  is  the  iirst  good  instance  of  the  kind  I  have  ever  met 
with. 

A  few  words  with  resj  ect  to  associated  morbid  con  Luons. 
The  condition  of  the  heart  in  autopsies  on  pneumonia  is  very 
characteristic,  so  much  so  that  anyone  with  tolerably  lar^e  ex- 
perience cnn  make  a  slirewd  guess  at  a  case  of  pneumonia  from 
the  condition  of  the  chamijcrs  of  the  heart.     They  are  usually 
found  distended  with  firm  clots,  so  firm  thai  they  can  be  with- 
drawn from  the  blood  vessels  ;  and,  as  you  saw  in  the  cases  this 
week,  the  clots  could  be  withdrawn  from  the  pulmonary  artery 
to  its  finest    .Tiificun  us.     Th     -   is  no  disease  in   which  you 
meet  with  fibunous  clots  of  the  same  degree  of  firmness  and 
extending  the  same  length  into  the  veins.    The  excess  of  fibrine 
in  the  blood  in  fLis  disease  accoiints  for  the  exceeding  firmness 
of  these  clots. 

It  is  very  rare  to  meet  with  ..iher  morbid  conditious  in 
pneumonia.  We  usually  fin  1  the  organs  healthy,  exce[.t  the 
shght  changes  associated  h  '  '.^rh  fever,  if  of  '  i,g  stand- 
ing, the  turbidity  of  the  v;i  us .  ms.  The  state  of  th°e  spleen 
IS  ot  some  interest,  particuhuly  as  to  the  point  wh-fher  pneu- 
monia is  a  local  disease  or  a  general  essential  fever.  Professor 
Fredreich,  of  Heidelberg,  calls  attention  in  one  of  his  lectures  to 
the  fact  that  the  spleen  is  usually  much  enlarged  in  pneumonia. 


Ih  very  ti 

has  been  ( 

been  of  n( 

change,  tli 

of  the  kid 

with  pneui 

chronic  at 

Bristowe  c 

in  this  aftei 

cases,  a  v( 

ours,  it  lias 

instance  of 

carditis  is  a 

of  cases. 

we  have  ha 

occurred  in 

plication  of 

of  cases.  In 

and  four  of 

xigor.     The 

single         e 

the   palu 

pain  in  the  s 

shortness  of 

under  your  i 

lias  pain  in  t 

are  the   pre 

when    you  ( 

whom  we  lia 

and  short  res 

these  feature 

a  case  when 

To  analyse 

of  breath  is  d 


*  Vide  papers 
national  Altdic 


PNEUMONIA. 


25 


Ih  very  many  of  the  autopsies  tli;,t  I  have  pcrfoniiod,  the  spleen 
has  heen  enlarged  ;  Init  in  fully  half  of  the  eases  the  o.-an  has 
been  of  normal  size.     The  kidneys  rarely  show  any  important 
change,  though,  as  I  will  tell  you  in  the  next  locture,  the  state 
of  the  kidneys  influence  the  prospects  of  an  individual  effected 
with  pneumoiua.     In  a  vjry  considerable  number  of  the  cases, 
chronic  atrophic  clianges  are  met  with  in   the   kidneys      Dr.' 
Bristowe  called  attention  to  croupous  coUUh,  a  sort  of  dysentry 
m  this  affection.     He  met  with  it  sixteen  times  out  of  some  48 
cases,  a   very  considerable  proportion.     la  these   GO  cases  of 
ours,  It  has  only  occurred  on  f'.o  occasions,  an.l  there  was  one 
instance  of  croupous  or  diphtheritic  gastritis.    Ulcerative  endo- 
carditis is  a  complication  of  which  we  had  a  consi.lerable  number 
of  cases.     Out  of  the  twelve  instances  of  this  disoase  whidi 
we  have  had  in  this  Hospital  in  the  past  few  years,  seven  have 
occurred  in  connection  with  imeumonia.*     Meningitis  is  a  com- 
plication of  which  we  have  also  met  with  n  considerable  number 
of  cases.  In  the  GO  autoj.sies  there  were  five  cases  ,.f  meningitis, 
and  four  of  these  were  associated  with  endocarditis. 

V«p<oms.— The  affection  is  usually  ushered  in  with  a  distinct 

iigor.     'I'here  is  no  disease  which  so  constantly  begins  with  a 

single         n-e  chill.      Following    this- in    fact,    during    it- 

the  pau.       bocomes  feverish,  and  usually  complains,  too    of 

pain  in  the  side.     The   next  symptoms  in  or.Ier  are  cou-h  and 

shortness  of  breath  ;  and  with  these  the  patient  usually^comes 

under  your  observation.     He  has  had  a   rigor,  is  feverish,  and 

has  pain  in  the  side,  with  shortness  of  breath  and  a  cough    These 

are  the   prominc.t   features    that    you   meet    with    in    c- -.Qi 

when   you  e.xamhio  them  first,  as  you   saw   in   that   woima 

whom  we  have  .just  left  iti  ward  24.  The  flushed  face,  the  quick 

and  short  respirations,  with  dilating  alee  nam—so  striking  are 

these  feu  lures  in  many  instances,  that  you  can  at  once  recognize 

a  case  when  you  enter  the  ward. 

To  analyse  these  symptoms  a  little  more  closely  ;  the  shortness 
of  breath  is  due  to  several  distinct  causes.     In  the  first  place, 


•  Vide  papers  in  Seguias  A  cliiv,,  1881.  and  Transaction"  nt  ♦h-  f-tor 
nutiona!  Miditai  Congress,  London,  1881,  "'       


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26 


SI'HMER   SE8SI0N   CLINICS. 


the  fever.  Tlicre  is  increased  need  of  oxygen,  and,  consecinently, 
the  respiratory  movements  have  to  bo  increased  in  luuuber.  We 
see  the  iinpc    ance  of  this  factor  in  the  dysj)noea,  when  the  fever 
loaves  at  the  crisis  ;  though  there  may  be  no  change  in  the 
amount  of  consolidation,  yet  the  respirations  will  sink  from  Ah 
or  50   to  nearly  normal.       Another  cause    of    the    dyspnoea 
is  the  amountof  solid  exudation  ill   .10  lung — the  breathing-space 
is  very  considerably  diminished.     And  thirdly,  there  is  usually 
enough  pain  in  the  side  to  prevent  the  patient  taking  a  long 
breath.     These  are  the  three  chief  reasons  for  the  increased 
respiratory  raovi'ments  in  pneumonia.     The  fever  ran'^o  is  ex- 
tremely characteristic  ;  it  reaches  its  height  suddenly,  and  is 
maintained  throughout  the  course  of  the  disease  with  only  slight 
variations,  the  evening  temperature  being,  as  a  rule,  higher  than 
the  morning,  but  the  variations  are  not  extreme.    The  tempera- 
ture may  reach  from  104^  to  10(P,  but  it  is  more  common,  as  in 
the  cases  you  have  been  watching  in  ward  11,  for  the  tempera- 
ture not  to  rise  above  10-]  or  104.     The  most  striking  feature 
about  the  temperature  is  the  sudden  fall  at  what  is  called  the 
crisis  of  the  disease,  which  usually  happens  upon  the  fifth, 
seventh  or  ninth  day.     In  this  the  temperature  suddenly  drops 
perhaps  as  much  as  7  degrees.     You  visit  your  patient  in  the 
evening  ;  you  find  him  sitting  up,  the  respiration  oO,  the  pulse 
130.     You  leave  him,  feeling  not  a  little  anxious  as  to  his  con- 
dition. The  next  morning  you  find  him  lying  comfortably  in  bed  ; 
respiration,  24,  the  pulse  85  or  90,  and  the  temperature  normal 
or  even  subnormal.     The  crisis  has  taken  place,  and  you  are  at 
once  relieved  of  anxiety  as  regards  the  patient.     There  is  no 
other  disease  that  we  know  of  in  which  the  transition  from  ex- 
treme danger  to  comparative  security  takes  place  with  such 
rapidity.     In  neither  of  the  cases  we  have  studying  has  the 
termination  by  crisis  taken  place  in  the  typical  manner.     The 
temperature  did  not    fall   with  that  abruptness   seen    in  the 
typical  cases.     There  were  one  or  two  drops  or  jumps  before 
the  normal  temperature  was  reached.    The  cough  in  pneumonia 
is  characteristic.  It  is  short,  hacking,  and,  as  it  were,  restrained. 
The  patients  do  not  like  to  cough,  because  it  hurts  them,  and 


they  const 

expectorat 

amoiuit,  ai 

amomit  of 

So  glutino 

not  run  oui 

rusty  colon 

The  expect 

expcctorati 

above  cases 

persons  tlie 

juice  colour 

tion.     The 

110  to  lyi 

filled.     Aa 

requires  w£ 

feebleness  0 

as  the  treatn 

system,  as  i 

therapeia." 

increased,  tl 

no  reaction ; 

requires  spe 

several  occa 

following  cir 

of  the  fever, 

may  be  delir 

duals,  and  p; 

volved.      In 

may  amount 

This  form  is 

where  the  pa 

ing  aged  and 

perhaps   is 

individuals  v 

liquors.     Ye 

man  was  tak( 


'f^ 


rNEDMONIA. 


27 


thoy  constantly  appear  to  suppress  it,  owing  to  tho  pain.     The 
expectoration  in  the  early  sta^e  is  exceedingly  viscid,  small  in 
amount,  and  of  a  rusty  colour,  being  admixed  with  a  certain 
amount  of  blood.     This  viscidity  is  one  of  its  marked  features 
So  glutmous  is  it  that  you  can  turn  the  spittoon  over  and  it  will 
not  r.m  out.     Fn  the  latter  stnges  it  becomes  more  fluid  •  the 
rusty  colour  is  less  marked,  and,  it  may  be,  more  muco-purulent 
llie  expectoration  is  never  very  profuse.     You  rarely  find  the 
expect.)ration  of  •>  \  hours  amount  to  half  a  pint.    In  none  of  the 
above  cases  has  the  expectoration  been  excessive.  In  debilitated 
persons  the  expectoration  may  be  more  liquid,  and  of  a  prune- 
ju.ce  colour.     In  old  persons  there  may  be  very  little  expectora- 
tion.    Ihe  ^.i..  at  the  outset  is  full  and  bounding,  ranging  from 
1  0  to  130.     Ihe  heart  acts  forcibly;  the  arteries  are  well 
filled.     As  tho  disease  advances,  the  pulse  gets  weaker,  and 
requires  watchm-  with  great  care.     Increased  rapidity,  with 
feebleness  or  intermission,  should  at  once  attract  your  attention 
as  the  treatment  hinges  largely  on  the  condition  of  the  circulatory 
system,  as  ,s  well  expressed  by  an  old  maxim,  "  sine  puha  nulla 
therapeia.       The  urine   is  usually  high-coloured  ;  the  urea  is 
increased,  the  chlorides  are  diminished.     Nitrate  of  silver  gives 
no  reaction  ;  albumen  is  occasionally  present.  A  symptom  which 
requires  special  comment  is  delirium.     As  I  have  told  you  on 
several  occasions,  delirium  in  pneumonia  may  occur  under  the 
following  circumstances  :-In  the  first  place,  from  the  intensity 
ot  the  fever,  just  as  in  any  acute  febrile  afteetion  an  individual 
may  be  delirious  at  the  outset.    Secondly,  in  debilitated  indivi- 
duals, and  particularly  when  the  apices  of  the  lungs  are  in- 
volved.     In    these   cases   it   may   be   a    low   delirkim,  or  it 
may  amount   to  a  heavy  stupor,  with  occasional    mutterin-s 
Ihis  form  is  particularly  seen  in  what  are  called  asthenic  cases 
where  the  patient  is  much  de!)ilitatod,  and  in  pneumonia  attack- 
ing aged  and  enfeebled  persons.     Thirdly,  the  most  important 
perhaps   is    the   delirium    accompanying    the    pneumonia   in 
individuals  who  are  accustomed  to  take  largely  of  alcoholic 
liquors.     Yesterday  you  had  an  illustration  of  this.     A  youn-^ 
man  was  taken  ill  on  Friday  ;  he  had  a  chill,  and  has  since  been 


m 


I 


i\: 


I  : 


'>■  >      \  M  it 


ii 


D   !■ 


I    4| 


28 


SUMAIEB   SESSION   CLINICS. 


suffering  witli  the  usual  symptoms  of  pneiiraonia.  We  found  him 
in  tlie  ward  restrained  by  the  nurse  and   an  attendant.     The 
cheeks  were  flushed  ;  but  what  attracted  attention  at  once  was 
tlio  restless  eye  )f  the  patient,  and  his  anxiety  to  get  out  of  bed 
and  get  away.     He  was  actively  delirious,  and  the  delirium  was 
of  the  character  resembling  delirium  tremens.     As  you  saw, 
he  was  picking  at  the  bed  clothes,  and  when  I  went  at  first  to 
the  bed-side  he  was  talking  to  an  imaginary  person  on  the  other 
side  of  the  bed.     Tliis  feature  is  of  extreme  importance  for  you 
to  bear  in  mind,  because  you  may  overlook  the  essential  charac- 
ter of  the  disease.     You  may  treat  your  case  as  one  o?  delirium 
tremens,  when   in   reality  it  is   pneumonia,  complicated  with 
peculiar  delirium.     I  remember  an  instance  of  an  individual 
who  was  confined  in  a  strait  jacket,  and  believed  to  have  delirium 
tremens.     There  were  no  special  lung  symptoms.     A  few  days 
after  we  had  an  autopsy,  and  it  was  found  that,  he  had  extensive 
apex  pneumonia.     In  the  majority  of  those  cases  the  apex  of  the 
lung  is  affected,  as  in  the  young  man  you  saw  yesterday.    Occa- 
sionally the  delirium  is  exceedingly  violent.     A  few  weeks  ago 
I  performed  an  autopsy  for  Dr.  Rodger  at  Point  St.  Charles  on 
a  man  who  was  furiously  delirious  for  three  or  four  days  during 
the  disease.     He  required  several  strong  men  to  hold  him  in  his 
bed,  and  he  died  simply  exhausted  from  the  violence  of  his  efforts. 
The  stage  of  resolution  may  be  supposed  to  come  on  with  the 
crisis.     In  this  the  patient  is  tolerably  comfortable, — does  not 
complain  of  much  except  perhaps  a  little  weakness,  and  you  often 
have  difficulty  in  keeping  him  in  bed,  as  you  remember  in  the 
young  lad  (Case  III.) 

With  reference  to  the  physical  signs,  I  may  briefly  state  the 
following  : — In  the  first  place,  on  inspection  you  notice  that  the 
affected  side  does  not  move  as  much  as  the  opposite  one  ;  the 
intercostal  spaces  are  not  bulged,  nor  is  the  side  as  a  rule  en- 
larged, the  latter  being  distinctions  between  pneumonia  and 
pleurisy.  The  apex  beat  is  not  displaced.  Palpation  gives  aii  in- 
crease in  the  tactile  fremitus  ;  the  voice  sounds  are  communi- 
cated 1,0  the  fingers  through  the  solidified  lung  very  much  more 
readily  than  through  the  air-containing  lung  of  the  opposite  side. 


Percussion 

passing  into 

tympanitic  r 

tensity,  fron 

of  that  mai 

quire  an    ec 

But  usually 

to  the  close, 

more  or  less 

surface  of  th 

and  you  feel 

flatness  is  u 

pleuritic  effu 

In  the  firs 

hepatisation, 

at  the  end  of 

crepitant  rak 

listen  to  in  th 

by  the  crackl 

the  fingers  oi 

tised,  the  bre; 

character,  sin 

sterno-clavicu 

scapular  regie 

is  simply  the  i 

out  of  the  bro 

not  transmitte 

tied  lung,  bee 

exudation,  am 

always  have  ( 

cases  of  pneui 

feeble,  tubulai 

stages  you  the 

more  abundan 

These  persist 

lution  proceedi 

able  to  follow 


PNEUMONIA. 


29 


Percussion  in  the  early  sta-e,  when  the   engorgement  is  just 
passing  into  red  hepatisation,  gives,  over  the  affected  area,  a 
tympanitic  note,  which  may  be  of  very  varied  degrees  of  in- 
tensity, from  a  full  tympanitic,  such  as  you  heard  over  the  chest 
of  that  man  Phillippe,  to  a  flat  tympanitic  note   that  may  re- 
quire an    educated  ear  to  recognize  the   tympanitic    quality. 
But  usually  in  following  a  case  of  pneumonia  from  its  inception 
to  the  close,  you  meet  with  tliio  tympanitic  (luality  of  the  note 
more  or  less  marked.     In  the  full  hepatisation,  if  it  reaches  the 
surface  of  the  lung,  you  then  get  an  absolutely  flat  or  dull  note, 
and  you  feel  an  increased  sense  of  resistance  (>n  percussion.   The' 
flatness  is  usually  not   so   ivooden   as  in   cases  of  extensive 
pleuritic  effusion , 

In  the  first  stage,  and  as  the  engorgement  is  passing  on  to 
hepatisation,  you  have  what  is  called  the  pneumonic  crepitus  ; 
at  the  end  of  inspiration  you  hear  a  series  of  extremely  fine  dry 
crepitant  r-iles.     They  are  the  finest  and  the  dryest  nlles  you 
listen  to  in  the  chest,  and  may  be  compared  to  the  sound  made 
by  the  crackling  of  salt  when  burning,  or  to  the  rubbing  between 
the  fingers  of  a  bunch  of  hair.     When  the  lung  is  fully  hepa- 
tised,  the  breathing  becomes  distinctly  bronchial  or  tubular  in 
character,  similar  to  the  sound  you  hear  in  the  bronchi  at  the 
sterno-clavicular  joints  or  adjoining  the  vertebn>3  in  the  inter- 
scapular regions.     You  must  remember  that  this  bronchial  sound 
is  simply  the  normal  sound  which  the  air  makes  passing  in  and 
out  of  the  bronchi,  but  which,  in  the  case  of  a  healthy°lung,  is 
not  ti  ansmitted  to  our  ears  with  the  same  intensity  as  in  a  solidi- 
fied lung,  because  in  the  latter  the  air-cells  are  filled  up  with 
exudation,  and  transmit  the  sound  much  better.     You  will  not 
always  have  this  evidence— bronchial  or  tubular  breathing~in 
cases  of  pneumonia  ;  in  many  instances  it  is  weak,  and  has  a 
feeble,  tubular  character  as  resolution  proceeds.     In  the  later 
stages  you  then  begin  to  have  rules  which  are  raoister  and  much 
more  abundant,  and  accompany  both  inspiration  and  expiration. 
These  persist  for  a  very  considerable  [)eriod  of  time.     As  reso- 
lution proceeds,  the  dulncss  usually  dimimslies  ;  and  as  you  were 
able  to  follow  in  that  case  of  the  lad  (case  III),  certain  areas  of 


1ft 


'.    !     I: 


3.  |P' 


iin 


■  f 


30 


SUMMER   SESSION   CLIMCS. 


the  lung  cleared  up  entirely,  and  you  got  a  full  resonant  note. 
It  is  net  at  all  uncommon,  as  in  his  case,  for  the  base  of  the  lung 
to  remain  slightly  dull  for  a  long  time  ;  that  dulness  may  be  due 
to  diminished  resonance  in  the  lung,  or  to  a  thick  layer  of  pleuritic 
exudation  in  that  region.  The  heart  sounds  present  no  special 
changes  further  than  that  the  second  sound  at  the  pulmonary 
cartilage  is  increased  in  intensity. 

The  profinosis  in  the  disease  is  usually  good  ;  but  it  depends 
much  upon  the  class  of  individuals  you  have  to  treat,     Thus  the 
prognosis  in  cases  admitted  into  this  hospital  is  not  as  good  as 
in  the  cases  outside  among  the  better  classes.     The  mortality 
here  is  exceptionally  high,  in  some  years  over  20  per  cent. 
A  large  number  of  the  cases  die  within  48  hours  of  their  admis- 
sion.    In  the  170  cases  of  pneumonia  treated  by  Dr.  Howard 
during  20  years,  the  mortality  was  between  5  and  (3  per  cent. 
In  some  40  consecutive  cases  which  I  have  had  in  the  past  three 
years,  most  of  them  in  this  hospital,  there  have  been  but  three 
deaths.     Among  the  circumstances  that  influence  the  prognosis 
are  :  1st,  Age.     As  you  may  suppose  elderly  individuals  do  not 
resist  the  fever  as  well  as  young,  healthy  persons.     2nd,  The 
habits  of  the  individual.     Drunkards  and  persons  debilitated 
from  any  cause  aro  exceedingly  bad  subjects  to  take  pneumonia, 
and  it  usually  in  them  early  assumes  an  asthenic  type.     That  is 
one  reason  why  our  mortality  is  so  high.     We  get  sent  in  here 
chiefly  the  lower  classes  and  debilitated  individuals  ;  and  very 
many  of  the  cases  of  pneumonia  are  in  persons  in  the  habit  of 
taking  a  considerable  amount  of  alcohol.     3rd,  Existing  disease 

is  an  important  factor.    In  persons  who  receive  an  injury as  a 

broken  leg—and  then  take  pneumonia,  the  disease  is  more  liable 
to  run  an  unfavourable  course  than  an  healthy  person.  Inter- 
eurrent  pneumonia,  as  it  is  called,  is  always  more  serious  than 
an  attack  in  a  healthy  person.  Of  all  aflfcctions  that  would 
seem  to  have  a  bad  influence  in  pneumonia,  chronic  renal 
trouble  comes,  I  believe,  first.  In  looking  over  the  records 
of  post-mortem f<,  some  00  in  number,  I  was  surprisc<l  to  find  in 
how  many  the  kidneys  wore  stated  to  be  oxira  firm  or  roughened, 
or  the  capsule  did  not  remove  readily— facts  pointing  to  chronic 


h 


PNEUMONIA. 


31 


atrophic  changes  in  the  organs.   Dr.  Goodhart  of  Guy's  Hospital 
has  called  attention  to  this  fact.  "y^puai 

We  now  come  to  the  important  subject  of  the  treatment  of 
pneumonia,  and  the  lessons  you  may  learn  from  this  should  con- 
stitute your  "  pnncipia  "  in  therapeutics.  The  first  is  that  there 
13  an  inherent  tendency  in  many  diseases  to  recovery  quite  irres- 
pective of  any  treatment.    In  a  remarkable  work  by  that  remark- 
able man,  t  e  late  Jacob  Bigelow  of  Boston,  entLd  "  Natui' 
.n  Disease,';  he  lays  down  the  proposition  that  most  affections 
are  self-bnuted      II.s  words  are  as  follows  :  "  Bv  a  self-limited 
.sease  I  would  be  understood  to  express  one\vhich  rocdves 
hmits  from  its  own  nature  and  not  from  foreign  influences,  and 
which,  after  it  has  obtained  a  good  hold  on  the  system,  cannot 
m  the  present  state  of  our  knowledge,  be  eradicated  or  abridged 
by  art,  but  to  which  there  is  due  a  certain  succession  of  proces^'ses 
to  be  completed  after  a  certain  time,  which  time  and  processes 
may  vary  with  the  constitution  and  condition  of  the  patient,  and 
may  tend  to  death  or  recovery,  but  are  not  known  to  be  short- 
ened or  greatly  changed  by  medical  treatment  " 

Pneumonia  is  a  strictly  self-limited  disease-in  fact,  the  most 
strikingly  so  of  any  with  which  we  are  acquainted.  We  cannot 
cut  It  short,  the  cases  run  a  definite  course. 

The  second  lesson  is  that  nature,  in  ^he  majority  of  ca.es  is 
quite  competent  to  restore  the  patient  to  health.  '  The  natural 
therapeutics,  as  Professor  Harvey  of  Aberdeen  calls  the  vis 
medacatrix  naturae,  in  contradistinction  to  applied  thera 
peutics,  are  capable  in  80  per  cent  of  cases  of  dealin.^  with 
the  disease  As  Professor  Guebler  puts  it,  "  L'or.^a'iisme 
seguerit  lui  me^.e"  Cases  III  and  IV  received  nol  ^c" 
treatment  beyond  a  little  Liq.  Ammon.  Acet.,  and  the/both 
made  satisfactory  recoveries. 

Let  me  advise  you,  before  worshiping  at  any  special  thera- 
peutic shnne  to  pay  your  vows  to  Nature,  taking  the  motto  of 
Edmund  m  Lear  "  Thou.  Nature,  art  my  goddess,  to  thy  law 
my  services  are  bound."  ^ 

The  third\.,,on  is  that  the  functions  of  the  physician  are  to 


co-operate  with  Nature,  to  aid  her  wi 


lure  she  fails,  and,  above 


}f 


[I    ■   i; 


ii'      ^i|       i 


-t 

) 

■:.     f 

^ 

'    1     ■ 

:; 

r'r 


^:  i-: 


!• 


.    '■    i 

1 

.- ;,. 

] 

i 

! 

'% 


r 


32 


SDMMER   SESSION   CMNirS. 


all,  to  combat  certain  tendencies  to  a  fatal  issue,  which  tenden- 
cies are  duo  cither  to  an  inherent  or  acquired  viciousncss  of  con- 
stitution, or  the  intensity  of  the  inflammation.  And  here  arises 
the  importance  of  an  accurate  knowledge  of  the  natural  history 
of  any  disease  in  order  that  we  may  recognize  early  fatal  tenden- 
cies and  be  on  our  guard  against  impending  dan"er. 

Now,  let  us  apply  these  principles  to  the  treatment  of  pneu- 
monia.    In  the  first  place,  as  I  have  just  stated,  the  majority  of 
cases  do  perfectly  well  when  left  to  themselves.     It  is  a  self- 
limited  disease,  and  though  for  the  sake  of  the  patient,  and  still 
more  for  the  sake  of  friends,  you  may  have  to  give  a  "  placebo," 
the  treatment  is  outside  of  your  own  hands  ;  it  is  in  the  hands 
of   Nature.      You   may  give    what  you  like,    and   you  may 
flatter  yourself  that  you  are  curing  the  disease,  but  the  percent- 
age of  mortality  has  been  shown  to  be  just  as  light  on  the 
expectant  method. 

What  are  the  fatal  tendencies  in  cases  of  jjuoumonia  ?  for  on 
the  answer  of  this  hinges  the  whole  (juostion  of  treatment. 

In  the  first  place,  exhaustion  by  tlie  fever.     Fever,   when 
long   continued,   or   when   high,   is    always   dangerous  ;    and 
to  reduce  the  fever  is  one  of  the  first  indications  for  treatment. 
When  not  above  103°  or  103J^  I  do  not  think  it  calls  for  any 
special  ireatment ;  but  where  it  is  above  104°  or  105°,  as  in  the 
case  of  that  woman  you  saw  a  few  minutes  ago,  you  should  use 
antipyretic  remedies,  choosing  the  ones  you  think  best.    If  you 
were  in  Germany,  where  physicians  and  patients  are  accustomed 
to  the  system,  you  would  give  the  patient  a  bath  ;  but  we  have 
never  been  able  to  introduce  the  cold  water  treatment  here.    The 
antipyretic  remedy  which  I  have  most  faith  in  is  (piinine.     The 
fever  in  that  woman  you  saw  before  the  lecture  was  105°  ;  she 
has  been  given  25  grains  of  quinine,  and  I  shall  be  disappointed 
if  in  a  few  hours  the  temperature  is  not  down  to  101°  or  102°. 
In  my  experience  there  is  no  better  remedy  for  reducing  tem- 
perature than  large  single  doses  of  (luinine.     We  have  had 
numerous  proofs  of  it.  and  where  you  have  a  remedy,  the  adop- 
tion of  which  has  been  tried,  grapple  it  to  your  therapeutic  soul 
with  hooks  of  steel. 


PNEUMONIA. 


33 


affected  mvt  nf\h.  1  ^'^  condition  of  the  un- 

.uitciLd  part  ot  the  Junes  varies  vorv  m,^nh      r 

the  areas  iro  in  o  .faf     r  •  !        "^  "     -^"  ^'^"''^  instances 

amount  „f  l„„„d  el  i„!;  L  Zi„      ^    r''"'-'"^"' "'^ 

s7,tol»        :  °?^"''  "'"'  '""  '°  '""™»  "'«  force  of  the 

b     area      t  e  ,"7   '  ""'  ""  ""■-'°r»''""i"S  off  a'consider- 

su  0    „  I  f  ;r        "^  '^"°'"  ''  '°  '""■»»*  ""^  blood  pre.. 

ZIZ  t^f  """"  .  '''"'•  "•«  '""-"»"  i»  "'«  Wood 
dTn  e?  "■^,^'';«™"'pi-='i  i"  certain  inslanees  by  great 

of  e,™  f!d  'It"  "'T "-^^ ■■»"-«  *™»'™»  by  ex'dttion 

P  .'    ".of  It    '""^J"""  "  ™"'''"-'"  *''^'»>  of  the  other 

pneumon  a  but  looking  over  my  reports  of  »,(-„„,«  eases  of 
l.neu,„„„,a  ,t  struck  me  as  not  a  lit  e  remarkable!  l! 
wa»  the  healthy  part  of  the  lung  neither  ^ge*        "XT 
ous.     llns  state  of  collateral  cedema  is  doubtless  impomnt  ;„ 
some   n,sta„ees,   though    not  as   much   so  as  some  "   iTk  it 
Anot  er  effect  of  the  impe.led  How  of  blood  throu^L  Z  .t 

::..te  u  ^ot:}  ;?z:Tstt't  t  t-  '"''''-'' 

Then   acnin  in  n  n v      .      ,  J<ept  up  to  its  standard. 

Ihon,  again,  in  addition  to  these  sources  of  embarrassment  of 
he  heart,  yon  have  the  influence  of  fever  on  the  heart  m^,' "  e/ 
When  fever  lasts  for  an,  time,  there  is  muscular  weakne"   T  c 
action  of  fever  produces  degeneration  and  weakness  of  the 

pneumonia  .s  largely  due  to  the  fever.     In  nine  out  of  ton 
serious  cases  of  pneumonia,  the  tendency  to  ,..t^:tX.^ 


H 


■  ^  - '    1  ■ 


?■' 


l^i 


!S»r,i:^..^, 


'f 


34 


SUMMKR   SESSION   CLINICS. 


Now,  how  is  that  to  be  couiitcractetl  ?  In  the  first  place,  through 
stinmhmts.  If  I  hud  my  choice  to  treat  the  next  oO  cases  of 
pmumonia  whicli  will  fiill  under  my  care,  with  all  the  remedies 
of  the  pharmiieoprcia  at  my  disposal  without  alcohol,  or  with 
alcohol  alone,  I  would  say,  Let  rac  have  the  alcohol.  I  have 
seen  in  this  disease  better  effects  from  this  medicine  than 
from  any  other  with  which  I  am  acquainted.  Juergeuson, 
in  his  article  on  pneumonia,  fully  cxpres;-c3  my  opinion 
as  to  the  efficacy  of  alcohol  in  this  disease,  when  he 
says  that,  "  It  is  not  only  the  whip  to  the  horse,  but  the  oats 
as  well."  When  you  find  your  patient's  pulse  foil,  when  it 
begins  to  flicker  ;  if  it  runs  up  and  gets  weak,  begin  your 
stimulants  at  once.  Do  not  wait ;  you  cannot  do  any  harm  by 
giving  a  few  ounces  of  whiskey  in  a  day,  even  early  in  the 
disease,  more  particularly  if  your  patient  is  of  debilitated  habit. 
In  the  cases  III  and  IV,  tlie  patients  were  pretty  healthy  indi- 
viduals, both  with  moderate  attacks  of  the  disease,  and  they  did 
not  need  it ;  but  in  the  cases  land  III,  alcohol  was  given  freely 
and  early.  So,  pin  yoar  faith,  if  to  nothing  else,  to  alcohol,  in 
pneumonia.  Of  other  cardiac  stimulants  which  may  be  used  in 
certain  instances  with  great  benefit,  I  would  next  mention 
camphor.  Three  and  four  grain-doses  of  camphor  in  the  form 
of  emulsion,  or 'spirits  of  camphor  in  25  to  oO  drop  doses,  have, 
in  some  instances,  an  astonishing  effect.  Musk,  in  \  to  2  grain- 
doses,  may  also  be  given,  and  I  have  seen  benefit  from  it. 

Shall  we  bleed  in  pneumonia  ?  This  is  an  important  question. 
And  if  we  should  bleed,  when  ?  Now  I  would  say  this  at  the 
outset,  that  the  man  who  never  bleeds  in  pneumonia  will,  if 
his  experience  is  large,  certainly  lose,  in  the  course  of  his  ex- 
perience, several  cases  that  he  would  have  saved  if  he  carried  a 
lancet  in  his  pocket  and  used  it ;  whereas  the  man  who  will 
carry  and  systematically  use  the  lancet  in  pneumonia  will  lose 
many  patients  that  he  otherwise  might  have  saved.  The  chief 
indications  for  the  use  of  a  lancet  arc  when,  in  a  strong,  full- 
blooded  individual,  the  right  heart  is  seriously  embarrassed, 
over-distended,  when  there  is  intense  dyspnoea,  and  when  there 
arc  signs  of  the  beginning  of  pulmonary  oedema.     Some  of 


you  may  ri 

11,  whose 

XXV ->.     Tl 

condition, 

in  the  carli 

out  any  vie 

here  nor  th 

fever.     Tin 

heart.     Of 

larly  if  reso 

majority  of 

Shall   we  g 

viride,  and  t 

they  are  not 

to  the  chest 

in  this  hospi 

to  the  patiei 

with  apparei 

What  sha 

And  how  lor 

rule  is  for  re 

ten  days  the 

in  which  no 

fever  keeps 

quietude,     1 

mation  of  al 

seventh  or  eij 

completely  re 

the  fifth  and  i 

cleared  up  sa 

I  will  just  s 

individuals  ai 

tained  yesten 

I  do  not    kn( 

a  few  days  di 

*  Canada  Lan 


PNEUMONIA. 


35 


you  may  remember,  two  years  ago,  the  case  of  a  man  in  ward 

'  : ''  L  ^'W  ^^'''''^'  ^^'•'^^  '^''''^  V  timely  venesection  to 
XXV  >  Ihe  relief  vas  something  remarkable.  Tlie  only  other 
cond,t.on,  I  believe  in  which  you  can  bleed  with  satisfaction  is 
n  the  early  stage  whe.e  you  have  a  full,  vigorous  man,  with- 
out any  v.ce  of  constitution.  Twenty  ounces  of  blood  is  neither 
here  nor  here  n.  such  a  man,  and  it  will  reduce  his  pain  and 

beai  t.  Of  course  uKhviduals  may  die  from  exhaustion,  particu- 
larly If  resolution  does  not  take  place,  as  in  case  IV  ;  but  in  the 
majority  of  fatal  cases  of  pneumonia  they  die  of  cardiac  failure. 
Shal  we  give  arterial  sedatives-digitalis,  aconite,  veratrum 
v.nde,  and  the  like  i  Except  at  the  onset,  and  in  vigorous  persons, 
bey  are  not  indicated.  Antimony  I  never  use.  Local  treatmen; 
to  he  chest  IS  often  advantageous.  We  use  poultice,  very  much 
m  us  hospital,  and  they  are  soothing  to  the  ,,ain  and  grateful 
to  !.e  patient.  I  never  use  cold,  though  I  have  seen  it  applied 
with  apparent  advantage  in  German  hospitals 

What  shall  we  do  if  resolution  does  not  take  place  normally  ? 
And  how  long  can  a  lung  remain  solid  without  dama^^e  '     'Ao 
rule  IS  for  resolution  to  begin  after  the  crisis,  and  in  a  week  or 
ten  days  the  lung  ,s  pretty  clear  ;  but  there  are  many  instances 
in  which  no  crisis  takes  place,  the  lung  remains  sol'],  a  sli!. 
fever  keeps  up,  and   the  patient  may  cause  you  mental  lis- 
quietude      lou  may  fear  the  breaking  of  the  Inng  and  the  for- 
mat..,n  of  abscesses,  but  even  if  resolution   be  delayed  to  the 
seventh  or  eighth  week,  it  may  ultimately  follow  and  tl^  lun.  be 
comj^etely  restored.     I  reported*  one  case  which  was  delayed  t 
the  hfth  and  another  to  the  eighth  week,and  then  the  lung  in  both 
cleared  up  satisfactorily,  and  the  patients  made  good  rec^overies 
will  just  supplement  my  remarks  on  pneumonia  of  debilitated 
dividuals  and  drunkards  by  shewing  you  this  specimen,  ob- 
tained yesterday  from  a  patient  of  Dr.  Wilkins.  a  feeble  old  man 
1  do  not    know   his  habits ;  he  came    in    delirious,   and  after 
a  few  days  died  with  cxcensive  pneumonia  of  the  right  apex  of 

*  Canada  Lanett,  December,  jyso. 


': 


:!'i 


1:1 


If 


%  V 


36 


SUMMER   SlESSION   CLINtCS. 


III! 


the  Iiing.  You  see  here  the  whole  of  the  upper  lobe,  with  the 
middle  lobe,  uniformly  solid.  It  weighs  over  2,000  grammes. 
There  is  a  pleuritic  exudation  over  the  surface.  On  section, 
you  see  that  it  is  of  a  reddish-grey  colour.  I  show  you  this  to 
impress  upon  you  the  lesson  you  should  have  learned  from  the 
case  you  saw  in  the  wards  yesterday,  as  it  is  somewhat  similar 
to  it,  and  on  account  of  the  fatal  issue  of  so  many  of  these  cases. 


No.  V. 

leucocythemia; 


Gentlemen, — There  are  certain  diseases  which  affect  princi- 
pally the  blood  and  the  organs  of  the  haematopoietic  system. 
Of  these  the  princi[)al  are  : — 

1.  Ancemia. 

2.  Chlorosis. 

3.  Leiicooythemia  ;  and 

4.  Lymphadenoma,  or  Hodykins''  Disease. 

These  are  characterized  by  profound  alterations  in  the  constitu- 
tion of  the  blood,  and  certain  of  them  are  accompanied  by  definite 
changes  in  those  organs  of  the  body  which  we  regard  as  the 
blood-making  ones.  The  form  of  anaemia  which  particularly 
belongs  to  this  class  is  that  known  as  pernicious  or  essential. 

Of  the  affections  characterized  by  an  alteration  in  the  struc- 
ture and  appearance  of  certain  of  the  blood-forming  organs,  the 
most  important  are  leucooythemia  and  Hodgkins'  disease.  In 
these  affections,  either  the  spleen  alone,  the  lym[)hatic  glands 
alone,  or  the  spleen  with  the  lymphatic  glands  are  affected. 
In  the  former  we  have,  in  addition  to  the  changes  in  the  spleen 


*  Hteuographica!  rv';t>!-!  hy  .lams-s  CvankshaWj  Ksq,,  B.C.L 


and  lymph 

terized  by 

the  term,  ] 

there  is  no 

though  tli( 

identical ;  1 

to  it.     I  ha 

Smith  and 

case  illustri 

and  yet  one 

and  well. 

— •  Vervi 

moulder,  bu 

in  Montreal 

dead  of  an  i 

strained  whi 

of  hands  an 

the  belly  be^ 

in  left  side. 

blood  in  stoc 

him  about  I^ 

Trenholme,  i 

ment  of  the  i 

of  several  pi 

be :  dropsy, 

ness,  and  sho 

the  patient  I 

better  in  him 

We  will  nc 

he  presents. 

larged  abdom 

not  nearly  as 

not  present  a 

much  better  t 

healthy  look  a 

breathini:  is.  i 

■ 'n   examuiat 


I 


LfcTi«  OCyTUEMlA. 


3t 


\ 


and  Ij^raplmtic  glands,  a  special  alteration  in  the  blood,  charac- 

enzecl  by  a  great  nicreaso  in  the  colourless  elements.     Hence 

he  term,  Leucocythemia,  or  Leukemia.     In  Hodgkins'  disease 

here  ,s  no  such  mcrease  in  the  number  of  colourless  corpuscles, 

though  the  characters  of  the  changes  in  the  organs  may  be 

Identical ;  hence  the  term  Pseudo-Leukemia  is  sometimes  Jm 

to  It      1  have  here  to-day,  owing  to  the  kindness  of  Dr.  Lapthorn 

Mnith  and  of  the  patient  himself,  an  exceedingly  interesting 

case  illustratmg  a  disease  met  with  but  rarely  in  this  country" 

and  yet  one  which  it  is  very  important  for  you  to  know  accurately' 

and  well.     The  history  of  this  case  is  as  follows  • 

--  Vervais  et    39,  has  been  a  healthy  man.     Has  been  a 
moulder,  but  for  the  past  eight  years  kept  an  hotel.  Always  lived 
in  Montreal.  Never  had  ague.  Mother  died  at  age  of  80  ;  father 
dead  of  an  accident.     Got  hurt  17  years  ago  in  the  left  side  ; 
s  ranged  while  lifting.  Ill  now  for  13  months ;  began  with  swelling 
of  hands  and  legs,  which  continued  for  five  or  six  months ;  then 
the  belly  began  to  swell.  Had  pain  in  belly,  and  noticed  a  swelling 
in  left  side.     Occasional  vomiting  in  morning.     Never  passed 
blood  in  stools,  or  vomited  it.     No  palpitation  at  heart.     I  saw 
him  about  New  Year's  in  consultation  with  Drs.  Kingston  and 
Irenholme,  and  we  found  great  oedema,  with  ascites  and  enlarge- 
ment of  the  spleen.    Since  that  time  he  has  been  under  the  care 
of  several  physicians.     The  chief  symptoms  have  continued  to 
be:  dropsy,  for  which  he  has  been  tapped  three  times,  weak- 
ness, and  shortness  of  breath  on  exertion.   Within  the  past  month 
the  patient  has  improved,  and  I  see  a  great  change  for  the 
better  m  him. 

We  will  now  examine  the  patient  and  ascertain  the  synptoras 
he  presents.  The  first  thing  you  notice  is  that  he  ha«  an  en- 
larged abdomen,  with  slight  dropsy  of  the  feet  and  legs  ;  this  is 
not  nearly  as  much  as  it  was  when  I  saw  him  last.  His  face  does 
not  present  a  specially  cachectic  appearance.  He  is  lookin-now 
much  better  than  a  month  ago,  but  has  not  got  ,,uite  so  good  a 
healthy  look  as  when  I  saw  him  first  about  the  New  Year.  The 
breathing  is,  you  notice,  a  little  short.  The  mhe  is  about  108. 
On   examination  wc  find    the    following  .-       le    abdomen    is 


if: 


38 


SUMMER   SESSION   CLINICS. 


uniformly  distoiKied,  not  more  on  one  side  than  the  other,  and 
raeadures  about  4-"  inches.     A  few  large  veins  arc   seen,  but 
they  are  by  no  means  prominent.     On  palpation,  the  abdominal 
walls  yield  ;  they  are  not  tense  ;  there  is  no  increased  sense  of 
resistance  until  the  fingers  reach  the  left  side  of  the  abdomen. 
You  then  feel  a  distinct  solid  mass.    It  is  firm,  hard,  and  reaches 
below  the  level  of  tlie  crest  of  the  ilium.     There  is  a  definite 
edge,  and  at  about  the  level  of  the  navel  and  at  a  distance  of 
three  inches  to  the  left  you  feel  a  distinct  notch  at  this  edge. 
This  resistant  mass  can  be  felt  well  into  the  left  hypochondriac 
region,  and  far  back  into  the  left  lum!)ar  region.     On  percussion 
there   is  a  dull  note,  while  over  the  greater  portion  of  the 
abdomen,  a  flat,  tympanitic  note  is  obtained.     In  the  umbilical 
and  the  hypogastric  region  there  is  a  distinct  wave  which  can 
be  seen   and  felt  on  percussing  one  side  of  the  abdomen.     So 
that  we  find  here  a  large  collection  of  fluid  in  the  abdomen, 
and  ev.  i-  ,!?es  of  a  tumour  mi  the  left  side.     The  liver  cannot 
be  fe]<.  V";'.).v  the  ribs  ;  its  upper  limit  of  dulness  is  half  an  inch 
belo.    .  ,i    supple.     The  chest  is  well  formed.     The  apex  beat  is 
in  tbt;  i'orth  interspace,  and  just  within  the  nipple  line.     On 
auscultation,  a  soft,  systolic  mui-mur  is  heard.    The  lungs  appear 
normal.     The  lymph  glands  are  not  enlarged. 

Now  what  we  have  found  here,  gentlemen,  is  simply  dropsy 
of  the  abdomen,  with  oedema  of  the  legs,  and  a  tumour  on  the 
left  side  of  the  abdomen.     3'he  tjuestions  are,  first,  what  is  the 
nature  of  this  enlargement  on  the  left  side  ?    What  is  the  cause 
of  the  dropsy  ?  and  of  the  tumour  here  in  this  region  ?     You 
would  think  at  once  of  an  enlarged  spleen  or  kidney.     When  I 
saw  this  patient  with  Dr.  Ilingston  and  Dr.  Trenholme,  the  doubt 
was  whether  it  was  renal  or  splenic.     It  is  so  far  back  in  the 
lumbar  region  ;  it  is  not  very  moveable  ;  and  it  was   thought 
that  perhaps  it  might  be  an  enlarged  kidney.    But,  on  the  other 
hand,  against  that  are  the  facts  that  the  !)order  can  be  felt  very 
distinctly  ;  a  notch  is  evident ;  and  on  percussing  and  palpating 
towards  the  left  hypochondriac  region,  it  is  found  that  this  mass 
emerges  from  below  the  ribs  on  the  left  side  ;  the  dull  line  ex- 
tends nearly  to  the  level  of  the  nipple.     From  its  position,  the 


distinct  fe 

from  the  1 

an  enlarge 

As  to  tl 

place,  to  t 

of  simple  i 

causes  uid 

called  splei 

spleen  of  h 

you  can  d 

the  blo(jd  V 

an  accurati 

now,  so  far 

the  spleen, 

blood.     If 

decrease  in 

it  a  case  of 

not ;  but  if 

puscles  gre; 

to  twenty,  c 

leucocytheir 

and  we  find 

eight  red  on 

tion  of  the 

affection,  m 

find  also  tha 

red  blood  coi 

There  is  alsc 

Of  me  cat 

everything  t( 

of  middle    f 

quently  in  cl 

of  an  infant 

affects  males 

which  have  b 

is  one  which 

I  have  lately  \ 


LEUCOCYTIIEMIA. 


30 


distinct  feel  of  the  edge  of  the  notcl,  and  tl.o  way  it  ni.orges 
from  he  left  hypocho.idrium,  there  is  no  ,l,H,ht  about  its  beh,. 
an  ctilargcd  sploen.  ° 

As  to  the  cause  of  that  cnlnr^omcnt,  you  have,  in  the  first 
P  ace,  to  think  of  chronic  malaria  ;  then,  in  the  second  place 
ot  simple  splenic  enhii-ornent  not  induced  by       '  Ha   but   hv 
causes  unknown  to  us,  accompanied  hy  an.«mi  .  sometimes 

ca  le<l  sp  etnc  an;omia  ;  and,  thirdly,  whether  this  .s  the  enlar^'cd 
spleen  of  leucocythemia.     Now,  the  only  possible  way  5n  which 
you  can  decide  between  these  conditions  is  by  examination  of 
the  blood  w.th  the  microscope,     t  is  impossible  for  you  to  make 
an  accurate  diagnosis  unless  you  proceed  to  this.     You  can  say 
now,  so  far  as  we  have  got,  that  it  is  a  case  of  enlargement  of 
be  spleen,  with  dropsy,  but  that  is  all  until  you   examine  his 
blood.     If  you  examine  this,  and  find   that  there   is  simply  a 
decrease  in  the  number  of  re<l-blood  corpuscles,  you  will  call 
It  a  case  of  splenic  anemia,  whether  dependent  on  malaria  or 
not ;  but  if  you  examine  it,  and  find  the  number  of  white  cor- 
puscles greatly  increased,  so  that  the  ratio  is  one  white  corm.scle 
to  twenty,  or  less,  red-blood  corpuscles,  you  will  call  it  a  case  of 
leucocythemia.     In  this  instance  the  blood  has  been  examined 
and  we  find  that  the  ratio  is  about  one  white-blood  corpuscle  to' 
eight  red  ones.     There  is  very  great  leuk^^mia.     The  examina- 
tion of  the   bloo,l  decides   the  .piestion  of  the    nature  of  the 
aflection,  namely,  that  it  is  a  case  of  splenic  leukaemia      We 
find  also  that,  in  addition  to  the  disproportion  of  the  white  and 
red  blood  corpuscles,  the  latter  are  greatly  diminished  in  number, 
mere  is  also  marked  ana;mia. 

Of  the  causation  or  etiology  of  the  disease  we  have  almost 
everything  to  learn.  It  occurs  most  frequently  in  individuals 
of  middle  period  of  life,  though  it  is  met  with  not  unfre- 
quently  in  children.  The  youngest  case  I  have  known  is  that 
of  an  infant  eight  months  old,  a  case  of  Dr.  Howard's.  It 
affects  males  more  frcpiently  than  females.  Of  circumstances 
H-hich  have  been  stated  to  influence  it,  in  some  respect,  malaria 
IS  one  which  by  many  is  thought  to  have  an  important  influence. 
1  have  lately  been  going  over  a  large  number  of  leuktemia  records 


I-  i ' 


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riiuiugifipiuu 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  NY.  14580 

(716)  873-4503 


.^'«^ 


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^i;*" 


40 


summj;r  session  clinics. 


i-l    ! 


particularly  of  American  cases,  and  I  have  been  surprised  *o 
find  how  few  were  the  cases  in  which  any  definite  connection 
with  malaria  could  be  ascertained.     We  know  very  little,  in- 
deed, of  t'^e  circumstances  which  induce  this  affection.     Of  the 
morbid  anatomy,  in  the  splenic  form  the  spleen  is  chiefly  involved, 
and  it  forms  a  large  cake,  as  it  is  called.  The  size  of  the  tumour 
may  range  from  a  couple  of  pounds  to  16  or  17  pounds.     Some 
of  the  largest  abdominal  tumours  are  of  this  splenic  variety. 
This  one,  from  a  patient  who  died  under  tiie  care  of  the  late 
Dr.  John  Bell,  is  the  largest  specimen  we  have  in  our  museum ; 
it  weighed  7  pounds  when  it  was  fresh.     Here  is  a  second,  not 
so  large,  and  a  third,  larger  in  proportion  than  the  others,  as  it 
was  taken  from  an  infant  eight  mouths  old.     The  organ  in  this 
affection  is  large  and  hard.  It  is  in  a  condition  of  what  is  called 
chronic  hyperplasia.     It  cut?  with  difficulty  ;  the  section  is  uni- 
form and  the  trabeculge   of  the  gland  are  unusually  distinct. 
On  examination  with  the  microscope,  we  find  that  the  change  is 
chiefly  in  the  network  of  adenoid  tissue  of  the  gland,  whicli  is 
greatly  increased ;  and  between  the  little  meshes  are  the  spleen 
corpuscles.     In  a  large  number  of  cases  the  lymphatic  glands 
are  also  enlarged,  more  particularly  the  lymphatic  glands  in  the 
neck  and  in  the  axillia,  less  frecjuontly  in  the  groins  and  in  the 
internal  glands.     The  enlargement  in  the  lymphatic  glands  is 
simply  hyperplasia.     They  are  enlarged  and  firm,  but  otherwise 
look  natural.     In  addition,  in  a  very  considerable  number  of 
cases  of  leukaemia,  there  ar  )  definite  growths  of  lymphoid  tissues 
in  organs  in  which  we  do  not  usually  see  such  growths.     Thus 
for  instance,  in  the  liver  you  may  have  definite  tumours,  whitish 
in  appearance,  varying  in  size  from  a  walnut  to  a  hen's  egg, 
composed  entirely  of  new  growth  of  lymphoid  tissue.     These 
may    also  occur    in    the    lungs.      The    glandular    elements 
in  the  small  intestines  are  sometimes  enlarged.     The  tissue  of 
the  bone-marrow  has  attracted  attention  in  this  disease.     It  is 
converted  into  a  reddish,  soft,  pulpy  material  very  much  resem- 
bling spleen  pulp.     It  is  believed  to  play  a  very  active  part  n\ 
the  production  of  many  of  the  features  of  the  disease    Neuman, 
Hosier  and  others  speak  of  a  myelogenous  form  of  leukjcmia,' 


induced  b 

changes  ii 

the  condit 

to  the  inc 

may  prest 

corpuscles 

coagulatio 

heart  file 

first  case 

opened   th 

precisely  t 

one  of  Vir 

an  absce?s 

filled  the  ; 

With  re 

attracts  at 

the  left  hy 

men.     Ac( 

patient  bee 

that  they  a 

ceed.s.     In 

and  of  the 

throughout 

dition  of  tl 

essential  s; 

The  foil 

leuk;emic 

finger,    yo 

drop  of  the 

brown  colo 

greyish-red 

as  one  raigl 

but  the  cole 

on  tho  inert 

the  red-bloo 

profound,  ai 

you  tind  the 


LEUC0CYTnE5:iA. 


#1 


induced  by  changes  i.i  the  bone-marrow.  These  are  the  chief 
changes  in  the  organs  and  parts  of  the  body.  In  post-mortems 
the  condition  of  the  blood  is  otten  found  most  remarkable,  owing 
to  the  increase  of  the  white  corpuscles.  The  blood,  when  clotted, 
may  present  a  greyish-red  appearance,  or  in  clots  where  the 
corpuscles  have  separated  from  the  iiquor  sanguinis,  before 
coagulation  has  taken  piace,  you  may  have  the  auricle  of  the 
heart  filled  with  a  substance  looking  like  pure  pus.  lit  the 
first  case  reported  in  Canada  (by  Dr.  John  Bell),  when  wt 
opened  the  right  auricle  of  the  heart,  Dr.  Bell  exclaimed  in 
precisely  the  same  terms  as  are  related  to  have  been  used  by 
one  of  Virchow's  assistants  in  a  similar  case,  "  Why,  we  have 
an  abscess  of  the  heart,"  so  puriform  did  the  clots  look  that 
filled  the  right  chambers. 

With  reference  to  the  symptoms  of  the  disease,  the  first  that 
attracts  attention  is  usually  a  sense  of  fullness  and  uneasiness  in 
the  left  hypochondriac  region,  or  in  the  upper  zone  of  the  abdo- 
men. Accompanying  *;his  there  is  usually  failing  health.  The 
patient  becomes  languid,  the  appetite  is  impaired,  and  they  notice 
that  they  are  paler  than  usual.  Dropsy  of  the  legs  soon  suc- 
ceeds. In  the  patient  you  have  just  seen,  dropsy  of" the  legs 
and  of  the  hands  appear  to  have  been  his  first  symptom ;  and 
throughout  the  case  it  has  been  the  chief  trouble.  The  con- 
dition of  the  blood  on  examination  is,  of  course,  one  of  the 
essential  symptoms  of  the  afifection. 

The  following  are  the  characters  by  wiiich  you  mav  know 
leukiemic  blood  :  In  the  first  place,  when  yoti  prick  the 
Hnger,  you  find  that,  instead  of  the  deep  purplish-red 
drop  of  the  normal  blood,  the  colour  is  changed  to  a  chocolate 
brown  colour,  or  even,  when  the  leukaemia  is  very  intense,  a 
greyish-red  colour.  In  this  patient  the  colour  is  not  so  marked 
as  one  might  expect  from  the  number  of  white-blood  corpuscles  ; 
but  the  colour,  you  must  bear  in  mind,  does  not  depend  so  much 
on  tilt-  increase  of  the  white-blood  corpuscles  as  the  decrease  of 
the  red-blood  corpuscles.  In  a  case  where  the  anfemia  is  very 
profound,  and  the  number  of  red  corpuscles  much  decreased, 
you  find  the  blood  almost  of  a  chocolate  colour.  On  examination 


0  J 


ft 

w 


•  i 


'  *, 


'.   I 


t  n 


42 


StrilMER    SKSSION   fl.INICS. 


with  the  microscope,  the  colourless  corpuscles  are   greatly  in- 
creased ill  number.     Instead  of  seeing  two  or  three  white-blood 
corpuscles  in  the  field  of  a  No.  7  Hartnack,  you   may  find  as 
raany  as  GO  or  70.     In  tact,  one  usually  supposes,  on  first  exami- 
nation of  leukiemic  blood,  that  the  white-blood  corpuscles  greatly 
exceed  the  red  in  number.     It  is  rather  a  hazardoas  thing  to 
estimate,  without  accurate  measuremnt,  the  proportion  of  white- 
blood  corpuscles  to  the  red.  The  red-blood  corpuc:.les  ai'e  always 
more  numerous  than  they  appear,  for  the  reason  that  they  collect 
together  in  clumps.     You  do  not  see  how  many  th'?re  are  owing 
to  formation  of  rouleaux  ;  whereas  the  white  corpuscles  remain 
isolated,  and  so  they  look  much  more  numerous.     Secondly,  the 
colourle.'^s  corpuscles  frequently  present  great  variations  'n  size. 
You  will  notice  this  in  the  slide  of  blood  which  I  have  here  for 
examination.     Some  are  mui.'h  larger  tlian  normal  ;  others  are 
smaller.     In  cases  in  which  the  lym|ihatic  glands  are  greatly 
involved — lymphatic  leuktemia — there  is  a  much  larger  propor- 
tion of  small  white  cor|)Uscles.  Thirdly,  the  red-blood  corpuscles 
usually  present  a  somewhat  paler  appearance  than  usual ;  occa- 
sionally there  are  gi-eat  discrepancies  in  size  and  irregularity  in 
the  outline.     Fourthly,  you  may  have,  added  to  the  blood,  an 
element  not  seen  in  health,  namely,  nuclear         Mj-blood  cor- 
puscles rt'hich  exist  normally  in  the  bone-marrou.     These  occur 
not  unfrequently  in  leuk;Braic  [)atients.     In  the  last  case  I  had 
they  were  remarkably  abundant.     In  one  instance,  in  the  field 
of  a  No.  9,  I  counted  ten  nucleated  blood  corpuscles.     I  never 
before   saw   them   .so   abundant.     Lastly,   Schultze's   granule- 
masses  are,  in  certain  cases,  vei'y  ar.merous.     These  characters 
you  will  see  in  the  specimen  of  blood  which  I  have  taken  from 
this  patient. 

Among  other  symptoms  in  connection  with  leid<;v;mia,  hemor- 
rhages take  a  prominent  place.  In  some  Instances  hemorrhages 
occur  very  freely,  and  may  be  the  very  first  symptoms  which  a 
patient  complains  or.  In  one  of  Dr.  Howard's  series  of  cases 
(Montreal  General  Hospital  Reports,  Vol.  I),  vomitin-  of  blood 
was  the  first  serious  symptom  that  the  lad  had.  In  another  in- 
stance, which  I  believe  to  have  been  a  case  of  leukiieraia,  the 


I 


girl  died 

to  this  a 

marked  i 

rhage  ini 

is  a  grav 

simply  t( 

one  case 

througho 

patients  i 

perature. 

his  tempe 

marked. 

the  condi 

doubtless 

haps  he 

which  woi 

mind  that 

on  the  pc 

This  patie 

The  pat 

largely  de 

and  deveh 

particulan 

the  blood  i 

associated. 

The  trei 

a  hopelessl 

bad  to  wo 

occasional 

the  patient 

that  the  pa 

due  to  the 

without  be 

spleen  was 

out  in  some 

either  died 

remedies   v 


LEUCnCYTUKTIA. 


43 


prl  died  of  tlic  most  profuse  lia>raatemesis.   She  appeared,  prior 
to  th.8  attack,  to  be  in  fair  health.     We  found  at  tl.e  autopsy  a 
marked  increase  in  the  colourless  blood  corpuscles.  The  hemor- 
rhage may  occur  early  in  the  disease,  or  as  a  late  symptom,  and 
13  a  grave  omen      There   is  usually  vomiting  ;  it  may  be'  due 
simply  to  the  pressure  of  the  large  spleen  on  the  stomach.     In 
one  case  o   Dr^Howard's,  the  vomiting  was  a  persistent  symptom 
throughout.     Diarrhoea  is  occasionally  met  with.     Most  of  these 
patients  are  febrile.    There  is  a  slight  evening  elevation  of  tem- 
perature.    Ihis  patient  has  not  had  much  fever.     I  have  taken 
his  temperatuie  several  times.  The  dropsy  in  this  man  has  been 
inarked^_   This  may,  in  greot  part,  be  anajmic,  depending  upon 
the  condition  of  his  blood.     The  marked  dropsy  of  the  belly  is 
doubtless  due  to  interference  with  the  portal  circulation.     Per- 
haps he  has  enlarged  glands  in  the  -^rnro-hepatic  omentum, 
which  would  account  for  the  dropsy  in  this  case.     But  bear  in 
mind  that  enlargement  of  the  spleen  alone,  without  any  pressure 
on  the  porta    vein    may  account  for  the  dropsy  in  the  belly. 
Tins  patient  has  a  heart  murmur,  an.^mic  in  character. 

The  pathology  of  the  affection  is  still,  unhappily,  very  obscure, 
largely  depending  upon  the  fact  that  our  knowledge  of  L  growth 
and  development  of  the  corpuscles  is  still  wanting  in  so  many 

rZT  .   V' '"'^  "'^'^^'^^  ""  '""P^''''  ^'-^  the  condition  of 
I'oclated'  blood-making  organs  should  be  intimately 

The  treatment  of  this  disease  is  highly  unsatisfoctory.     It  ig 

a  hopelessly  incurable  affection.     The  patient  usually  goes  from 

bad  to  worse.     Two  years  sees  the  termination.     There  ar^ 

occasional  intermissions  of  the  symptoms,  periods  during  which 

he  patient  im,,roves  a  good  deal.  It  is  one  of  these  intermissions 

that  the  patient  you  have  just  seen  is  in.     It  may  be,  of  course 

due  to  the  remedies ;  but  these  intermissions  are  known  to  occur' 

without  being  influenced  by  the  medicines.      Excision  of  the 

s,. leen  was  the  remedy  proposed  many  years  ago  ;  it  was  carried 

ou   in  some  18  or  20  cases  without  any  success.     The  patients 

either  died  on  the  table  or  shortly   afterwards.      The   chief 

remedies   which   have   been   used    have  been  directed  either 


'■I 


I .  .  .1- 


In 


III: 


*■'  iUi.    i: 


i     ■•         '  V 


1 

r 
» 

1    1 

) 

'1       1 

■k'    s,' 

:     1                 1 

^  ^\ 

f                 i 

1  j' 

1 

I  ,  ( 

1 

1  : 

^ 

1 

^ 

;■ 

J 

J 

i 
1 

1'. 

■     31 


44 


^fMMKIl    SESSION    CLINICS. 


towards  rcducihg  the  size  of  the  spleen  or  improving  the  general 
condition  of  the  patient's  health.  Among  the  remedies  used  to 
reduce  the  size  of  the  spleen  have  been  electricity,  which  has 
proved  very  serviceable  in  reducing  tlie  size  of  the  organ. 
Quinine,  also,  and  ergot,  given  internally  or  injected  into  the 
substance  of  the  organ,  have  been  used.  Of  the  medicines  used 
to  imi)rovc  the  general  condition  of  the  patient  and  the  blood- 
making  powers,  iron,  arsenic  and  iihosphorus  are  the  ones  com- 
monlv  employed.  This  patient  was  on  arsenic  for  some  timo^ 
and  also,  I  believe,  on  phosphorus.  He  is  now  on  iron,  and 
attributes  largely  his  im[)rovement  to  the  large  doses  of  iron  he 
has  been  obtaining.  Tranfusion  has  been  practiced  in  some 
cases,  in  the  hope,  [lerhaps,  of  giving  the  patient  a  better  blood  ; 
but  this  has  proved  futile.  In  a  i)atient — as  in  this  one  whom 
you  saw  here — with  extensive  dropsy,  you  have  to  relieve  the 
distressing  symptoms  by  tapping.  This  man  has  been  tapped 
four  or  five  times. 

There  is  one  symptom  that  I  did  not  refer  to,  namely,  the 
condition  ot  the  retina.  This  comes  in  under  the  symptom  of 
hemorrhage.  Many  of  these  cases  have  a  form  of  retinitis  wliich 
consists  of  hemorrhages  into  the  substance  of  the  retina.  This 
man's  retinte  are  normal.  The  patient  has  been  sent  to  one  of 
the  wards.  We  will  go  in,  and  some  of  you  will  have  an  oppor- 
tunity of  examining  him.  These  cases  rarely  occur  in  the  hos- 
pital. There  has  been  only  one  in  the  past  ten  years;  and  I 
am  sure  we  are  much  indebted  to  Dr.  Smith  for  allowing  liis 
patient  to  come  up  here,  and  giving  us  an  opportunity  of 
seeing  him. 


X  i-l  K 


>x 


li 


m  I 


CESTODE  TUBERCULOSIS.     '  ■ 

A  Successful  Experiment  in  Producing  it  in  the  Calf. 

By  PROFESSOR  OSLER.  M.D.  McGill  University,  and  A  W  CLEMENT, 
of  Lawrence,  Mass,,  student  in  the  Montreal  Veterinary  College. 

(Reprint  fioiu  the  American  Vbtkkinahv  Kevibw,  April,  1S82.) 


It  is  a  curious  fact,  and  (ine  that  requires  further  study  and 
explanation,  tliat  wliile  the  Taenia  Saginata  is  tlie  common  tape  worm 
of  this  country,  its  larvae,  the  measles  of  beef,  are  very  seldom  met 
witli.  On  the  other  hand,  wliile  T.  Solium  is  hy  no  means  so  prev- 
alent, yet  its  larvR!,  tlie  measles  of  pork,  are  not  at  all  infrequent. 
Cobbold*  refers  to  this,  and  states  that  "  not  a  single  instance  has 
been  recorded  of  the  occurence  of  these  cystic  parasites  in  the 
United  Kingdom,  except  in  our  experimental  animals."  Of  course 
much  more  fresh  beef  and  veal  is  consumed  than  fresh  pork,  and  the 
former  is,  as  a  rule,  less  thoroughly  cooked,  and  it  may  be,  as  we 
sliall  state  hereafter,  tliat  measly  veal  is  not  as  readily  detected  as 
measly  pork.  The  prevalence  of  tape  worm  is  directly  dependent 
upon  the  efficiency  with  which  the  meat  inspector  and  the  cook  per- 
form their  duties.  No  infected  carcass  sliould  escape  the  one,  and  a 
measly  steak  or  a  fillet  of  veal  from  the  kitchen  of  the  other,  could 
be  eaten  with  impunity. 

Experimental  proof  of  the  relation  between  the  beef  cysticercus 
and  T.  Saginata  was  offered  by  Leuckhart,  who,  in  1801,  successfully 
roared  the  measles  by  feeding  a  calf  with  ripe  segments.  Mosler, 
Giu-n  and  Zenker,  in  Germany,  St.  Cyr.,  in  France,  Perroncito,  in 
Italy,  and  Cobbold  and  Simonds  in  England,  have  repeated  the  ex-. 
♦Parasites,  1879. 


^r 


Ml'  (■  i 


'pii  'i 


'?<i 


'   , ;  ) 


'I 


J  t 
Is 

i 


periment,  in  most  inslaiifcs  witli  a  positivo  result.  So  far  aa  eonld  he' 
uscertiiiiied,  no  experiiiieiits  oi  the  kind  have  heon  luudc  in  America. 
In  order  to  procure  specimens  of  meiusly  veal,  and  to  afford  the 
students  of  the  veterinarv  college  an  opportunity  of  studyiu"  a  case 
of  cestode  tul»ercidosis,  we  fed  a  calf  with  fifty  i-ipe  segments  of  a 
tape  worm,  helieved,  from  the  characters  of  the  segments,  to  be  the 
T.  Saginata. 

The  animal,  a  female  calf,  aged  three  days,  weighing  seventy-five 
pQunds,  was  fed,  November  22d,  at  the  veterinary   colle<''e.     The 
temperature  after  tlie  feeding  was  103-4°.     The  animal  was  kept 
under  observation  for  seven  weeks,  and  a  daily  recjord  kept  of  the 
chief  symptoms,  whicli  brieHy  snnunarized,  were  as  follows:   Durin<>- 
the  first  week  no  special  cliange  wa-i  ol>served ;    the  animal  fed  well 
and  seemed  lively.      With  the  exception  of  the  observation  made 
just  after  the  feeding,  the  temperature  did  not  rise  above  102-5°. 
The  pulse  range  was  from  11 2  to  1 W.     The  fccces  were  soft,  one  day 
mixed  with  a  quantity  of  gelatinous  material.     No  segments  were 
observed,  but  microscopicnil  examination  on  the  third  day  after  feed- 
ing determined    the    presence   of   numerous  ova.      In    the    second 
week  the  animal  did  not  appear  so  well.     On  De(!eird)er  2(1  the  tem- 
pei-ature  rose  to  104-G^      The  pulse  kept  over  100.  of  moderate 
volume.     On  one  day  the  animal  seemed  stiff  in  the  limbs  and  disin- 
clined to  move  about,  Init  next  morning  was  jis  lively  as  before.    The 
f(eces  kept  tolerably  consistent ;   no  ova  were  found  on  subsequent 
examinations.     During  tlie  third  week  there  were  no  special  symp- 
toms to  attract  attention ;   the  food  was  taken  very  well,  and  super- 
ficial observation  would  have  judged  the  calf  to  be  healthy.     The 
temperature  kept  up  over  103°  and  on  two  days  above  104°.     The 
pulso  decreiised  in  rapidity,  sinking  below  100,  the  range  being  from 
86  to  95.    In  the  fourtli  week  the  temperature  was  above  104°  on  five 
days,  and  the  pidse  was  a  little  quickened.     There  were  no  intestinal 
symptoms ;  muscles  not  stiff,  and  beyond  a  slight  weakness,  the  animiil 
did  not  appear  very  ill.     During  the  fifth  and  sixth  weeks  the  staim 
quowHH  maintained;   temperature,  between  103°  and  104°;    pulse 
about  90.     During  part  of  the  Clu-istmas  vacation  the  daily  recor<l 
was  not  kept.     In  the  seventh  week  no  special  change;   food  was 
taken  well  and  the  animal  was  active.     It  had  got  thinner,  but  this 
may  have  been  owing  to  an  insufficient  supply  of  nourishment.     On 
January  12th,  fifty-one  days  after  the  feeding,  the  animal  was  killed 


:i9  it  Wii8  tliounjlit  that  tlic  cysticeri  had  sufficiently  developed.  Post- 
Mortem.—Yioi\y  woiuowhut  wasted  ;  panniculus  jidipu,su,s  tliiii.  Tlio 
geiieral  lymph  glands  wore  nineli  swollen.  Apart  from  the  presence 
of  the  measles,  notliing  uhnormal  was  found,  so  that  the  record  may 
1)0  limited  to  an  mseount  of  their  distribution.  In  the  ahdomen  they 
were  numerous  in  the  omentum  and  in  the  fatty  capsules  of  the  kid- 
neys. The  liver  was  almost  free ;  only  two  were  found.  Ea(!h  kidney 
contained  six  or  eight.  In  the  thorax,  none ;  in  pleura,  a  dozen  or 
more  in  each  lung ;  in  the  heart,  tolerably  numerous,  particularly  in 
the  right  ventricles.  They  were  very  evident  beneath  both  peri  and 
endo-(nirdium.  The  voluntary  muscles  wei-e,  as  usual,  the  fiivorite 
locality,  and  presented  a  moderately  abundant  infection.  The  dia- 
phragm did  not  contain  very  many.  The  tongue  was  in  places  thickly 
studded,  and  they  could  be  easily  seen  beneath  the  nmcous  membrane; 
of  the  skeletal  nmsdes  those  of  the  thorax  and  back  were  most 
affected,  and  every  muscle  contained  several  examples. 

^  As  regards  their  obvious  characters,  the  cysts  were  ovoid,  with 
semi-translucent  appearance,  and  usfially  a  central  opaque  spot.  They 
varied  in  length  from  three  to  six  nun.  The  cysts  were  tightly  em- 
braced by  the  intercellular  tissue  in  whi('h  they  lay,  but  a  little  careful 
tearing  was  sufficient  to  disengage  them.  Microscopical  examination 
showed  the  larva?  to  be  in  an  advanced  stage  of  development:  in  the 
majority  the  head,  with  its  disks,  was  well  formed;  some  \  .f  im- 
mature, and  the  head  imperfectly  developed. 

The  experiment  was  as  successful  as  could  be  wished,  and  wo 
have  procured  a  supply  of  measly  veal. 

Among  points  of  interest  in  connection  with  the  case,  the  symp 
toms  take  the  first  place,  as  the  clinical  history  of  the  affection  has 
not  been  carefully  studied  in  many  instances. 

The  severity  of  the  symptoms  in  any  case  of  cestode  tuberculosis 
will  depend  upon  the  number  of  ova  ingested  and  the  number  of  larvje 
which  penetrate  from  the  intestines  to  the  system  at  large.  The  more 
numerous,  the  greater  the  constitutional  trouble.  If  only  a  moderate 
number  of  ova  are  ingested,  the  animal  may  not  display  any  special 
symptoms.  In  Leuckhart's  original  experiment,  the  calf,  three  weeks 
old,  received  scarcely  fifty  ripe  segments,  but  death  followed  on  the 
twenty-fifth  day,  apparently  caused  by  the  eruption  of  the  cysticerci 
throughout  the  body.  In  one  of  the  calves  of  the  Cobbold-Simonds 
series,  over  four  hundred  ripe  segments  were  given  during  two  months, 


f  1 

'   1' 

1 

f^  Mr  WW 


J. 


r 
I 
I 
I 


\^ 


1 


\w%\ 


ti    f^     n- 


i  i 


Ij 


ill  I 


.yet  tho  uniniul  did  riof  uppcir  sorioiislj  ill.     Unt  when  kill,,,|,  if  wis 
ostnnutcl  tliat  ever  rwelve  iiiilli..n«  of  cysticorci  wcto  in  ti.u'ur.num 
Hii.i  flesh.    I„  fho  pruseiit  ii.staiico,  tlio  co.istitutionul  (li.sturl)Hnce'\vuH 
•sh-ht  iii.d   the  fever  nu.donitc,  iind  there  was  no  special  affection  of 
the  musrulai-  .system.     The  nunnul  teniperatiu-o  of  the  calf  in  about 
103°,  so  that  there  was  no  fever  until  the  second  week,  when  the 
tenipemture  run.:;e<l  to  nearly  105%-    .li^du   pyrexia  kept  up  throu-d. 
the  t  nrd,  foui'th  and  fifth  weeks,  and  it  was  the  persistence  of  this 
which  led  us  to  suppose  that  the  animal  had  become  infected.     Tliero 
was  no  sudden  rise  of  temperature,  such  as  might  be  supposed  to  occur 
at  the  period  of  mi-ration  of  the  pro8C(,lices.     I,i  Zurn's  case,  *whiel» 
IS  the  only  one  we  c.ui  fiud  witha  carefully  reco,-ded  (dinical  history 
the  temperature  range  was  much  higher,  and  the  general  disturbance' 
very  great,  death  own.rring  on  the  twentieth  day.     In  our  animal  the 
niore  severe  <-ourse  might  have  been  expected  from  the  large  number 
of  ripe  segments  administered  ;  but,  perhaps  the  passage  of  many  of 
tJie  eggs  in  the  beces  may  have  had  something  to  do  with  the  mild- 
ness of  the  attack. 

^^  How  does  it  happen  that  the  T.  Saginata  is  so  prevalent,  when 
Its     nieasle     is  so  scarce  i    Several  causes  bring  this  about.     In  the 
first  place,  the  beef  "  measle  "  is  smaller  than  that  of  the  pork,  and 
18  not  so  opuquo ;    m  conse.juence,  it  is  more  readilv  overlooked ;    we 
are  sure  tl.at  ay  meat-inspe<.tor,  unless  specially  instructed,  would 
have  /. W  the  flesh  of  our  experimental  calf.     The  larva,  did  not  at 
once  catch  the  eye  in  the  red  tiesh,  as  in  the  case  of  e,siice.cus  ceUn- 
los<„  but  re-iuired  to  be  looked  for,  though  five  to  six  mm.  in  lem^th 
Secondly  it  is  not  improbable  that  many  of  the  animals  from  whicli 
the  infected  meat  is  obtained  are  not  extensively  diseased,  but  present 
onb^  one  or  tw.>  examples,  easily  overlo.>ked  in  dressing  the    arcl 

b  le  of  a  tape  worn.,  or  even  many  segments.      And,  thirdly,  a  very 

pait'f  wlihr  'Tr"'"  '''  J"'"^^  ">  ^^'^  table,  the  centra 
S^W  "         "  """'  ''  '  temperature  sufficient  to  kill 

*Dio  Parasiten  des  Mcnschen  K„che„n.ei.s,or  „nd  zum  2te  Auflagc  1881. 


I     m 


Li 


eL 


[Rfprir.lc.l  from  Tin    Mi  i,i,m    Niu.,  July  2.,.  iS,S2.| 


N,    /^"■J'r 


A  CLINICAL  LECTURE  ON  EMPVKMA  \N1) 
ITS  ANTISMI'TIC  TREATMENT.' 

Ih-lhvn;/ al  Ih,  M,.nlrc.,l  C.ncal  //os/^ita/,  J,,,,,  .-.fth, 


!•'  hfl: 


IIV 


WIl.r.lAM  OSI.KK,  M.D.M.U.CM'.  I  ond 

-■KorHSSou  „„   ,  ,„  .ssT.TUTHS  O,-  MKO.C.NH,  Mc<;,tL  UNlVKHSlrV. 


\  \ 


.i-.mi.k.micn:  I  wish  to  speak  to  y„i,  to-day  on  the 
siibic.t  of  empyema  and  its  trcatnic-nt  bv  the  antiscpt  ? 
n>cthocI.     You  saw  yesterday  a  case  whicli  was  o,  c  - 

d- :icarr:;,o:?t;""^ '-'-''  ^"" '  -•'" "-  --• '» >-  '^ 

Mary    S.,    a-ed    twenty-seven,    was    admitted    June 
.ih.     Is  unmarrie.l,  a  servant.     .\„thin^  special  in    he 
family   history.     .She  has    been   a  heaUhy  ,ir        VoZ 
weeks  aoo  she  had  chills  an<l  pain  in  the  left  side'    no 
roi.Kh  or  expectoration.     .She  was  attended  bv  Dr  Mc" 
Lallum    who    diaj^nosed    i)leunsy.  and    on    ■rhur;dav 
June   1st,    drew    off  with  the   aspirator  three    pim     of 
urlMd;  Kreenish  yellow  fluid;  the  patient  u'ls    -cievecl 
-.v    this    tappino,   but    on     the    6.'-.    'he    temperature 
lud  risen  ;  she  was   not  so  well,  a   d  she  was'^rcJom- 
inended   to  come  to  the  hospital.     On  admission   she 
was    noted    to   be  pale,  fairl  •  well    nouris   e      cheJks 
hest' tiieTr'^f/''^'.^^^-      ^^"   exan.ination   of"!' 

r,;;  .f  r  '"'^''costal  spaces  were  not  so  distinct 
the  tactile  fremitus  was  absent.  Apex  beat  to  the  ri"  ht 
of  the  sternum.     On  percussion  there  was  dulness  over 


'  Reported  by  Mr.  S.  A.  Abbott,  of  ^the  Hansard  Staff. 


dilated.      P..pils  slightly  con.rac.ed;  ^::^l::'^:^^r' 


mo- 


Reprinted  from  the  Archives  of  Medicine,  Vol.  vii,  N^^n^iT^- 


I  ¥■  ii!i 


f 


yet  (lie  iill 
csfiiiiiifiMl 
uiid  tlt'sli. 
Hliglit  unci 
the  inU8(;a 
103°,  8o  i 
teiniH'iMtn 
the  third, 
which  led 
was  no  8U€ 
at  tlio  ])tT] 
in  tlie  oiilj 
the  teni})e: 
very  great 
more  sevo] 
of  ripe  .sej 
the  eggs  ii 
nesri  of  thi 
llow 
its  "  meas) 
first  pliioe. 
is  not  so  o 
are  sure  1 
huve  pussi 
once  catch 
losos,  but  I 
Secondly, 
the  infect* 
only  one  ( 
Calves  an* 
bile  of  a 
mnch  grej 
than  pork 
cooked, 
parts  of  w 
the  larvse. 


the  whole  liinK,  except  in  tlic  iiifia-clavicuhi    rej; 
Tlie    two  sides  were  of  vi[U.i\    si/e 
of  a  j,'()t)cl  (leal  of  pain,  and  the  skin 
On  auscultation,  the  liieathinL'  w 
and  dist.uu. 


ion. 


le  ( oniphoned 


SI 
•as  hypeiiustheti 
K  was  exceedingly  weal 
liL'  evenni^;  temperature  on  the  7th,  Hth 
and  (;th,  reached  nearly  102.  On  the  12th,  she  wa' 
agani  as|)irated  and  lifty-i)ne  ounces  o 
she  };()t  considerahle  relief  from  this, 
d   fi 


pus  re 


moved 


ere  reduced   from  about   forty  to  twentv-f( 


The  respiration 


minu 


e,  and  the  teinper.ituie  remained  at'ahout 


le 


the  mornin^f.  reaching   kxj 
20th,  tlie   temperat 
and  22d,  it 


in   th 


in  tl 
99"  in 


c  evening.     On  the 
|ierature   went   up  to    103.5°;  on  the  2isl 

m 


remained  at  ahout  102".     .She  did  not  see 


so  well,  and  we  then  determined 


ed  to  make  a  fret 
e  CISC  antiseptic, illv, 


tpen- 
Thc 


ig  in  the  chest  and  tre.it  th 
oper.ilion  was  performed  by  Dr.  Fenwick'  in  the  follow- 
mg  way.     He   made  .111    incision    in   the  eighth   inter 
costal  s|)ace  on  the  left  side,  on  the  outer  margin  of  th( 

inh'a-sc.ioular 


|)ular  region,  just  at  the  junction   of  this  with 


the  infra  .ixill.iry  region.     He  then  opened  the  pi 


cavity  and  put  in  a  silver  canula,  which  was 


scvera 


leural 


devised 


years  ago  by  Dr.  Roddick,  after  repeated  trial 
for  special  use  in  cases  of  empyema.  The  caiuil 
which  is  slightly  curved,  has  the  foil 


orifice  is  ov  d,  tl 


ide  II 


uige  surrounds  it,  t 


ree-(iuarters   by  one-half 


owing  dimensions 


ind  a  half  bv 


an   inc 
one  a 


iu\ 


lalf  inches,  Aud  provided  with  eyelets  for  tapes.  '  Tl 


tube   is   bevelled  at  it 


s  inner  eiul,  and  measu 


res  about 


two  inches  in  length,  and  has  twelve  small  perforation 
•\  shorter  tube  was  found  to  slip  out.    I 


it  h.is  been  used,  this  one  h 


IS  it  all( 


n  cases  in  which 
IS  given  great  satisfacti 


s  ot  very  free  drainage  from  the  j)leural 


and  being  solid  i)revcnts  th 


on, 
cavitv, 


and  secures  a  space  of  constant 


c  pressure  of  granulat 


tion- 


pus  can  exude.    As  you  saw,  the  most 


size  through  which  th 


careful  antise 


precautions  were  taken.     About   thiity-t 
pure  pus  were  removed.     It  was  dressed  anti 
cavity  was  not  injected  and  the  layers  of  : 


II' 


wo  ounces  of 


Pt 


Hie 
lauze 


soaked  m  i  to  |o  carbolic  acid!  w 
>ver  the  tube,  tl 


septically 
'  antiseptic 


Th 


recti y  I 

side  then  bandagei 

as  soon  as  the  disci.... 

last  night,  dressed  tl 

had  saturated  the  tow  and 


,     ere  placed  d 
w  was  placed  outside  this,  and  th 


e  rule  IS  to  repeat  the  dress 


m 


.4 


irges  get  to  the  edge.    Dr.  Duncan 

he  case  again,  as  the  disch.irgcs 

luze;  and  it  was  dressed 


*Die  Parasiten  des  Mcnschen  Kuchenmelsternnd  zum  2te  Auflage  1881. 


aK.iin  this  morninir.     \'ini  li  n,.  ,,,  .  ■ 

*■■""'■'-■ '"'-'>'' ''™.iu;:,r,s:;,'.''''!,;,';,';,';;;: 


/, 


cr 


^» 


i 

'■    , 

i 

1 

;ii  i 

s 

B*' 

li 


v.ry  weak  and  dcbilitaid      n     „.-•,,  ^""'''t'"". 

1"  the  result;    h.nvevor      r  ,   ,    ,^   ''''l  /^^ave  fears  as 

chest  was  dressed  w he  I'e  er  e  I  I  '''''>'  "'"'I'  ■'"'^'-" 
«1kc  of  the  dressin  l-n^  "'^' '''^^  liar^cs  reached  the 
(cAle.  the  te^;"    ;;•  .  '     .  """^  ^^-^"^k^  '•'^  --emained 


i  J 


feeble,  the  temperature 


'li^^charKe  j,r„t  less,  and  t 
fall  in 


le  a  satisfactory  recovers 
CASK    11.  was    under  our 
sessu)n.     'I'l 


^i<le.  It  lad  lasted  for  sever.']  ^'r^^^'"^^  "'"  the  left 
t^M.pcd  once  and  a  u amlt  of''"  i  ""''  '"-"  '''^^'  '^^■«" 
I'e  came  to  the  I  oX        l      '  f"  ''"^"i"  "f"'"     ^^''>^'" 

sweating  and  con^iSliieti^JlS^ii^X.;^' 


Reprinted  from  the  Archives  of  Medicine.  Vol.  vii.  No.  ^TA^riTTiiir"" 


\  1 1 


fi 


yet  tlie  iiH 
estimated 
and  tlt'sli, 
slight  and 
the  iiniscn 
103°,  so  1 
teinpei'atu 
tlie  third, 
Avliicli  led 
was  no  sue 
at  tlie  peri 
is  the  qnlj 
the  tenipe; 
very  great 
more  sevei 
of  ripe  86^ 
the  eggs  ii 
ness  'f  th( 
How 
its  "  nieasl 
first  place, 
is  not  so  o 
are  sure  t 
have  j?asse 
once  cat'jh 
losce,  but  r 
Secondly, 
the  infectt 
only  one  c 
Calves  aiM 
bile  of  a  • 
much  gres 
than  pork 
cot)ked. 
parts  of  w 
the  larvae. 


I  thought  also  at  the  time  that  he  had  some  affect 


ion 


of  the  apex  of  the  iiL,dit  hm^^  as  there  were  rales  ... 
that  leKion.  There  was  universal  dulncss  over  the 
left  side,  with  the  exceptii^n  of  the  infra-clavicular 
d  the  usual  physical   signs  of  effusion.     Dr. 


region,  an 


ou 


Fcnwick  operated  :n  the  way  I  have  described  to  y -.. 
the  case  was  dressed  antiseptically,  and  the  lad  made 
a  remarkably  good  recovery.     He  entered  the  hospital 
on  the  2Sth  of  May,  and  on  July  23d  he  left  completely 


lell 


having  gained  in  llesh  and  with  the 


healed.     1  exhibited  this  lad  al 


quite 


before  the  .Medico-Ch 


irurs'ica 


1  S 


so,  with  the  other  one 


ocictv,  a 


nd 


3th 


them  the  result  was  everything  that  could  be  wished. 


:a.sk  III. 


was  also  under  obser\at 


a  man  named  Clarke,  aged  about  fortv-threi 


ion  last  suinmer- 


in  the  hospital  for  a  coi 


He 


iiion  on  the  right  side.     There 


f  weeks  with  pleural  effu- 


was  irregular  fever,  and 


e  susi)ected  that  the  thiid  was  jjrobably  purulent.  Or. 
using  the  hypodermic  needle,  we  found  that  there  was 
pus,  and  he  was  treated  in  the  way  I  have  already  de- 
scribed. The  pus  was  drawn  off,  and  a.tiseptic  d'rcss- 
'" ere  applied  every  day  or  every  second  day,  ac- 


inars w 


cording  to  the  amount  of  the  discharge.     This 


man 


was 


s  admitted  April  19  and  discharged  Julv  4,  perfecth 
well,  having  been  seventy-five  days  in  hospital.  The 
tube  had  been  removed  several  weeks  before  he  left 
the  hospital,  and  at  the  time  of  his  discharge  the  breath 
sounds  were  audible  at  the  angle  of  the  scapula.  He 
had  improved  in  general  health,  and  he  went  back  to 
his  work.  I  saw  him  several  months  aft 
he  had  kept  well. 


erwards,  and 


These  three  cases  of  e 


tinctl 


mpycma  stand  out  verv  dis- 


the  fc 


y   in  my   memory,  inasmuch  as  thev  are 


amoiii 


in  tins 


w  instances  in  which  I  have  seen  good  recover 


dis 


case. 


It 


serious  thing  for 


isalwavs  reu'ar 


ded 


les 
its  an  exceedinglv 


a  person  to  have  pus  m 


tl 


le  pleun 


le 


cavity.  The  liability  to  constitutional  disturbance,  tl 
difficulty  of  geUingthc  suppurating  pleural  membranes 
to  granulate  and  heal,  are  well  known,  and  render  this 
disease  extremely  difficult  to  treat  satisfactorily.  I  iidc  r 
the  antiseptic  phm  I  believe  many  of  these  difficulties 
are  obviated.  In  these  cases  the  temperature  af'ei 
'ipeiation,  particularly  in  the  man  Clarke  and  in  the 


second  case,  remained  normal. 


and  it  would  seem  that 


*Die  Parasite,  des  Menschen  Kuchenmeistcr  «nd  ziun  2te  Auflagc  1881. 


if  there  is  no 

discharge,  this 

treated  antisept 

jority  of  instan 

tlisturbance.     C 

will  be  difficult 

.ipparatus:  perl 

siiable  that  you 

specially  to'sur 

circumstances,  1 

Init  where  you  h, 

follow  out' thest 

ii'on  as  you  cau 

tlwroiii^h  ih-iii)ia 

!he  c/it-st,  and  if 

have    excellent 

empyema.     A  tl 

Iieve,  essential,  ; 

not  appear  to  ni; 

mit  the  chest  or 

vided  you  have 

large,  and  in  a  sit 

piete,  then  I  do 

Hut  if  you  have 

make  a  counter^ 

and  wash  out  tho 

followed:  A  drai 

washed  out  with 

i'Hline.     I  have  s 

Hay,   and    I   mus 

children,  satisfac 

rare.     It  is  notori^ 

of  cnipyema   are 

records  of  such  c; 

rate  of  mortality, 

know  of  is  that'  1 

boston    City    Hos 

drainage  and  a  frt 

of  the  affected  sid 

ol   nineteen,  and 

l)royed.     These  rt 

;iiitisept:c  precautii 


'  Hosp 


dilated,      r 
Reprinted  fr 


Li 


.    J        •        ^"^>-'i'ic,  like  ail  ordinarv  ah'^mac  u.ii,>.-. 


Hospital  Reports,  2d  Series.  1877. 


^C 


p.  £ 
i 


>N  I  I 


m :  m 


i  I. 


r*    i 


^r'-M 


;1 


dilated 


Reprmted  from  the  Archives  ok  Medicine.  V^T^ITl^^r^^^-yT^^^^ 


t  I 


1  il 


Ill 


'  ( 


jet  tlie  sin 
estiiiiiited 
and  tlcsli. 
sligJit  iiud 
the  imisou; 
103°,  so  t 
tenipenitu; 
tlie  third, 
wliiciJi  led 
was  no  sud 
at  the  peri 
is  the  only 
the  tempei 
very  great 
more  sevei 
of  ripe  seg 
the  egg8  ii 
ness  of  Hit 
How 
its  "  nieasl 
first  place, 
is  not  so  o' 
are  sure  t 
have  passe 
once  catch 
losoe,  but  r 
Secondly, 
the  infecte 
only  one  o 
Calves  tkiii 
bile  of  a  i 
much  grea 
than  pork. 
cooked.     ] 
parts  of  wl 
the  larvffi. 


t  wish  you  to  think  that  it  is  only  under  this 


for  i  do  no 

plan  that  cases  do  wcl 

As  you  are  aware,  in  this  \vc 
chest  hrst;  and  the  rule  is  in  a  case  of  e 


man  we  aspirated  tlic 


nipyema  to 


draw  off  the  fluid  with  the  aspirator  at  least  once. 
(ew  cases  do  well  with  a  single aspiratio 


)n,and  in  childrci' 


this  is  almost  the  rule.     I5ut  in  adults,  unfortunatel 
the  case  usually  ^rocs  from  bad  to  worse,  unless    '   '■'■' 


free 


openin,-;   is  made.     In  these  four  cases  th 


s  a  very 
e  inter- 


costal spaces  have  been  of  sufficient  size  to  admit  thi 
tube.     In  some  instances  the  space  is  not  larj^e  enoui^h, 
and  you  may  have  to  resect  a  portion  of  a  rib, 
to  '^vt  plenty  of  rt)om 


in  ordei 


And  now  a  few  ^a'ueral  remarks  on  the  disease.     Ir 


some  cases  the  fluid 


the  outset.     In  the  case  of  this 
first  drawn  off,   was  turbid,  of 


ppcars  to  be  pm-ulent  almost  from 


woman,  the  fluid,  when 
I  cream-vellow  color, 


ind  probably  became  purulent  sliortlv  after  its  form 

tion.     ()f  course,  the  oidinarv  sero-hl ' 

Pl 


urinous  fluid  of 


eunsy  cont.tins  ninnerous  Icucocvtes,  and  the  c 


version  o 


a  m; 


f  such  a  simple  effusion  into  a  purulent 


Uter  of  multiplir.ition  of  these.     Purulent  fluid 


on- 
one  is 


simplv  the  serum  dei 


In  debilitated 


sely  inriltraled  with  the  leucocytes 


IS 


persons  the  fluid  is  much 


more  apt  t( 


become  purulent  than  in  the  stronj;  and  healthy.  There 
is  !)ut  one  invariable  and  sure  means  of  ascertainini,'^ 
whether  the  fluid  is  pus  or  not,  and  one  that  is  easily 
applied.     Take  your  hypodermic  needle,  and  thrust  it 


into  the  chest,   and   d 


die 
>f(  some  of  it. 


mpk 


enough  method,  but  one  which  is  not  often  enough  re- 


sor 


ted  t 


Tl 


lere  are  numerous  ijractitioners  th 


the  country  who  never  think  of  using  the  hypoderm 
needle  except  for  jjurposes  of  medication,  where 


rougliout 


ic 


)f 


almost  as  much 


mi  porta  nee  i 


n  d 


of  pleural  effusion,  or  of  doubtful  dul 
terior  part  of  the  chest,  you  need  i 
thrust  the  hypodermic  needle  into  th 


lagnosis. 


ness,  in 


In 
the 


IS  It  IS 
cases 


It 


IS  so  simple  an  operation  that  it  docs 


pos- 

lever   hesitate  to 

e  regions  affected. 


ome,  described   a 


the  indications  you  get  from  it  are  of  th 

Professor   liacelli,  of  R 
ago  a  new  sign  bv  wh 
and  i)uruleni   e( 
woman, 


no  Harm,  whil 
e  greatest  valiii 


fe\ 


year' 


k 


y  which  to  distinguish  between  simple 
"usions.     I  tried  it  in  the  case  of  the 
)ut  It  was  not  very  satisfactory.     It  is  as  fo' 


ws  :  The  affected  side  of  the  chest 


is  auscultated,  and 


♦Die  Parasiten  des  Menschen  Kuchen:neistcr  und  znm  2te  Auflage  1881. 


Ci 


AJ 


f-'  'i  i 


7 

peis  It  he  Muid  IS  serous,  the  voire  soimds  arc  con- 
veyed to  the  ear ;  if  ,t  is  a  purulent  tluid,  the  wl,is^,e  c  I 
sounds  are  not  so  conveyed.  In  some  instancesthis 
method  proves  useful,  and  in  some  it  does  not.  In  one 
case,  particularly,  it  proved  to  be  correct 

Another  point  worth  notin- is  that,  in  cases  of  simple 
>  Itision,  the  patients  usually  lie  on  the  affected  side 
"licreas.  in  .ases  of  purulent  effusions-why  it  is  I  do 
not  know,  but  it  has  been  specially  noted  by  Dr.  Chur 
ton,   of  Leeds,  and    I   have  obscrVed    it    inysel  -they 
usually  lie  on  the  opposite  side  ^ 

\Vhat  becomes  of  the  effusion  if  it  is  not  removed  ? 
I  may  be  absorbed.  Adhesions  form  between  t  e 
pleura  in  certain  parts,  and  you  may  have  multilocu  Ir 
empyema,  which  may  be  cured  naturally,  thou' 
-111  be  a  stru.^ule  and  tax  the  vitality  ofVhe  Tien 
t  may  perforate  into  the  lun.-  to  be  discharoed  th  ou"; 
the  bronchial  tul)es,  which  I  think  is  a  very  favorable 
nay       I  he  cases  we  have  had  in  this  hospita   of  per' 


^i 


na>  v^c]l.     f^^r.Ross   has  had   two  such  cases   which 
Ur.  VVilkins  has  a  case  at  present, 


recovered  perfectly.     .^. 

I  believe   in  the  wards,  in  which  the  pus  perfo'ratedVhe 

luuK  and  was  discharged   by  couKhino.     It  may  alsc^ 

perforate  the  diaphragm,  but  thatis  rare.     It  may     er- 

orate  e.xternally  (empyema  necessitatis)  anddischanc 

for  months  or  leave  a    permanent  pie  iral  h     da      A 

point  to  be  borne   in   mind,  in  cases  of  left-sided 'env 

pyema   when  they  begin  to  pass  towards  the  su  fi S 

■^  that   they    sometimes   pulsate,    and    the    pulsation 

IS  exceedingly  likely  to  be  confounded  with    la    of 

an  aneurism.     In  the  chronic  cases  the  patients  have 

inegular  fever,  and  the  prolonged  dischar>  e  is  likeK 

;o  .nduce  either  amyloid'diseas'e  of  the  o  I'^L,  o    e^^ 

ie,;^t:;s:'u;;;;fti:^i!.fr^^:s;'sr^in-,f^^- 

specimen,  which  was  taken  from  a  case  of  em^  en 

w.nch  the  patient  died  of  acute  pneum.nia^if   £ 

o^.posite  lung.     Y  ou  see  here  that  the  lung  is  tlattenec^ 


•f   hi  ;} 


\^uvu<>«unt«i»  »iiv*rfi« 


dilated. 


*.    UVjK,      >IUiJIIV.1-I. 


,  »v.i«ivo  wii  v-irccKTrunu  nose 


Pupils  shghtly  contracted,  reactto  light ;  ophthalmo 


Reprinted  from  the  Archives  of 


MEDICINE,  Vol.  vii,  No.  2.  April,  i882. 


'.  r> 


yet  tlie  h^ 
estiniatedi! 
and  tle.sli, 
sliglit  and' 
the  iniiscii,: 
103°,  so  t 
teinpei-atit; 
the  thii'd, 
wliicih  led 
was  no  sue 
at  tlie  peri 
is  the  only 
the  tempei 
very  great 
more  sevei 
of  ripe  aeg 
the  egg'3  ii 
ness  of  th< 
How 
its  "  nieasl 
first  place, 
is  not  so  o- 
are  sure  t 
have  passe 
once  catch 
losoe,  but  r 
Secondly, 
the  infecte 
only  one  o 
Calves  anc 
bile  of  a  1 
much  grea 
than  pork, 
cooked.     ] 
parts  of  wJ 
the  larv8e= 


8 


Among  the  advantages  of  the  antiseptic  method  in 
empyema  appear  to  be  : 

(i.)  Ample  provision  is  made  for  free  and  continu- 
ous drainage. 

(2.)  The  avoidance  of  putrefaction;  in  none  of  the 
cases  were  the  discharges  in  the  sUghtest  degree  offen- 
sive. 

(3.)  The  ease  with  which  the  operation  is  performed 
and  die  small  amount  of  trouble  entailed  in  the  subse- 
(|uent  dressings. 

(4.)  The  healing  is  more  rapid,  and  serious  conse- 
cpiences,  as  amyloid  disease  and  phthisis,  are  less 
likely  to  follow. 

Note— July  [I,  The  patient  operated  upon  on  tlic 
4th.  Has  done  remarkably  well.  Temperature  normal, 
except  on  one  evening;  dressings  changed  now  every 
third  day  ;  discharge  very  slight. 


*Dle  Parasiten  des  Menschen  Kuchenmelstcr  und  zun,  2te  Auflage  1881. 


[Kepi 

A  CLIl 

■,,     .         i 

Dilhh 


W 

I'KOFKSS 


(iIJN'TL 

subject  01 
method, 
ated  upoi 
clinical  n 
Mary    : 
6th.     Is  11 
family   hi 
weeks  age 
cough  or 
Callum,  V 
June   1st, 
tf.rbid,  gri 
by    this    t 
had  risen 
mended   t 
was    notec 
flushed,    t( 
chest,  the 
fight.     Th 
the  tactile 
of  the  steri 


Ropo; 


dilated.      Pi 
Reprinted  frc 


Li 


ccii^  y  /tittt,^ 


r/    CC 


J 


'  i^ii 


^ 


/^ 


C^t.  1 1  ^/ 


t**-* 


Aiti 


-^ 


<3-> 


/'       r//     /^    h-^n^-r-         a^f^  i.i.    tvi^/.  .iteuz. 


"      A///    f^'^^'l"'"'^'-' '■'■"">''"'"■;  Mi-.imA,.  Nkws,  July  29,  iS,S2.] 
f^ '  '  ■   itu  ^  ¥t-*^<-*-^  


(C-^i^ 


A  CLINICAL  LECTURE  ON  EMP\  EMA  AND  -^'  ' 

ITS  ANTISEPTIC  TREATMENT.' 

Dcnv.',-e.l  a/ tkr  Afon/n-a/  G,;n;-al  Hospital,  Jmu-  j.,//,, 


4 


m  I 


■  I 

■?■   ill 


BY 


WIIJ.IAM  OSLKK,  .M.]).,.M.R.c.]'.  I  om, 

PKCPKSSOK  UP  TilE  INSlTrUTHS  OH   ME.,IC1N,5,  MC.^ILL  CNIVKKSM  V. 


Gkntlkmkx  :  I  wish  to  speak  to  you  to-day  on  the 
subiect  of  einpyema  and  its  treatment  bv  the  antiseptic 
n  ethod.  \  ou  saw  yesterday  a  case  which  was  oper- 
•itccl  upon  in  this  way,  and  I  will  (irst  read  to  you  the 
clinical  report.  ' 

Mary  S.,  aged  twenty-seven,  was  admitted  [unc 
6th.  Is  unmarne.  ,  a  servant.  Nothin-  special  in  the 
family  history.  She  has  been  a  healthy  ^irl.  Four 
weeks  ago  she  had  chills  and  pain  in  tlie  left  side-  no 
cough  or  expectoration.  She  was  attended  by  Dr.  Mc- 
tallum,  who  diagnosed  pleurisy,  and  on  Thursday 
June  1st.  drew  oft  with  the  aspirator  three  pints  of 
i.ibd,  greenish  yellow  fluid;  the  patient  was  relieved 
by    this    tapping,    but    on    the    6th    the    temperature 

mended  to  come  to  the  hospital.  On  admission  she 
uas  noted  to  be  pale,  fairly  well  nourished,  cheeks 
flushed  temperature  103°.  On  examinatior  of  the 
chest,  the  left  side  did  not  expand  as  mucn  as  the 
u  MrHh  f  >»tfcostal  spaces  were  not  so  distinct, 
the  tact  le  fremitus  u  as  absent.  Apex  beat  to  the  righ 
of  tlie  sternum.     On  percussion  there  was  dulness  over 

1  Repoitfd  l,y  Mr.  S.  A.  Abbott,  of  "tl^HansaVd  Stuff         ' 


dilated. 


»  V 11  trr^w  \j  I 


Pupils  slightly  contractej^j;eac^^oji^.  ophthalm 
Reprinted  from  the  Archives  of  Medicine,  Vof^liy^^r^pTiTiiir 


I    •  r' 


l<     ' 

r 
) 


lit  > 


:ll 


1 


'J-:  III 


t] 
1 

tc 

tl 

VI 

w. 
at 

is 

th. 

vei 

mc 

of 

the 

neg 

its 

firsi 

is  n 

are 

hav< 

once 

loam. 

Seco 

the  i 

only 

Calv 

bile 

inucl 

than 

cookt 

pm-ts 

the  la 


the  whole  "-^..except  in  the  -  --clav.u  a    r  H.on. 

'^\  .3  deS'orjSn;  a,;^  tile  Jl^in  w.^  llype.f  heti. 
(hwSulUU  on    tie  breathing  was  exceechnKl>-   weak 

-"'•ar'";\c^nS:^r^^rs^r"SS^^; 

'::.l;'sn  rued  and      tv-one  ounces  of  pus  removed  ; 
sl^e    ,r         cle> able  relief  fron.  this.     The  respnat.ons 
uxrcd.  ed  fron.   about  forty  to  twenty- our  in  the 
^Z  and  the  --pe.ature  re.n.ned  at^ou^^ 
the  mornniK,  reaching    loo    in   the   ""^^^'^^     ^^^  ^  ,^^ 

E^^thelsStSs-:^J::n^^^^^ 

K.r  Ui  n  was  performed  by  Dr.  Fenw.ck  in  the  follow- 
n^  wav.     He   made  an   incision   in  the  eighth   inter- 
costal  space  on  the  left  siae,  on  the  outer  margin  of  the 
fnV,?sr   nul  ir  re<^ion,  just  at  the   lunction   of  this  with 
SSSa'  xi  ..n--egi<H..     He  then  opened  the  pleura^ 
cavit       nd  put  in  a  silver  canula,  which  was  devised 
Scvei  a  year    ago  by  Dr.  Roddick,  after  repeated  trials, 
for       ecial   use   in  cases  of   empyema.      The   canula. 
!  hich  is  sli-htlv  curved,  has  the  following  dimensions: 
fice    s  ov       three-ciuarters  by  one-half  an   inch;   a 
de  lai  g    sunounds  it,  two  and  a  half  by  one  and  a 
If  inches,  and  provided  with  eyelets  for  tapes.      Fhe 
c   is  be  -elled  at  its  inner  end,  and  measures  about 
'.inches  in  length,  and  has  twelve  small  Perf!Hations 
A  shorter  tube  was  found  to  slip  out.    In  cases  in  which 
k  has  been  used,  this  one  has  given  great  satisfacUon, 
as  it  allows  of  very  free  drainage  from  the  pleural  cavity, 
and  being  solid  prevents  the  pressure  of  granulations 
ad  secuies  a  space  of  cnstant  size  through  which  the 
pu    can  exude.   As  you  saw,  the  most  careful  antiseptic 
precautions  were  taken.     About  thirty-two  ounces  of 
pure  pus  u  ere  removed.     It  was  dressed  ant.sep tically 
The  cavitvwas  not  injected  and  the  layers  ot  antiseptic 
crauze,  soaked  in  i  to" 40  carbolic  acid,  were  placed  di- 
?ectlv  over  the  lube,  tow  was  placed  outside  this,  and  the 
side  ihcn  bandaged.    The  rule  is  to  repeat  the  dressing 
as  soon  as  the  discharges  get  to  the  edge.     Ur    Duncan, 
last  night,  dressed  the  case   again,  as  the   discharges 
had  saturated  the  tow  and  gauze  ,  and  it  was  dressed 


*Dle  Parasiten  des  Menschen  Kuchenmeistcr  und  zuni  2to  Auflage  1881. 


riRiiin  this  morninu-,     y,,,,  j,,,,,^.  • 

tient  IS  ,n   a  romfortable  ro,ulit  on  to'd   v      V   e  U  m 

iiiLu  and  eiKlit.     She  expresses  herself  as  feelin..  v.-v 
easy,  and  ux-  liope  she  will  do  as  satisfactorilv^s  th  - 

ase^whidT'h'r'?",''!? ''•>■""•     ■'■'-i''henn,;'h 
i-ascin  unich  I    have  had  the  i)at  ents  treated  un    tho 

weir  l'^Tu^''''\  ""'  ^^  ">' >■  ''^^^  ^''--'"-ua 

•X  S-ul:^!)'''  ''?'  r''"^  V'^"'  "■^^''^''  i"  H'i'^  ^^ay  was 

r ^    rss;    u    h      '"^^  '^''''  ''^''^';^  '"'  ^^'l'"  "-^^^  admitted  June 
rp,  r.SSo   with  empyema  of  kft  side;  all  the  nhvsir  ,1 

s^the'  ;;s['h';d  1  "^ ''"'  '"^^ !"  '^-'-  -  "-^E 

In  V,  ' ,''''''"  aspiratetl  once  by  Ur.  Ross  ■ 

a  cj^",ernr2"'"' '  '"'^'^  "'^'^^  '  respiration;!;'"!; 
n   tin  '  ^    '  '  ^^^■'-'''^""K'-     "le  tube  was  inserted 

v^f  ^.  aili'd^b^JuSVJnd  wru?;Sv^';?if  1^ 

tii   c  oi  tnc  cliessin>,r.     !•  or  some  weeks  he  renninorl 

a?  o'y  ^'xfr^'T'"'""  ^'"""  ">'  -casion!ui  -T  '      , 
as  103  .     Alter  about  a  month  he  beiran  to  imnrove    h^ 

discharge, ot  less,  and  the  side  of  ^he  1^3  e^an  '  o 
;iV   •■  u    !''''  ■''  t''V''^^'"^»t  of  '^''"»'t  t^vo  months  he  wis 
matenally  better,  dischar.^e  very  slight,  and  o    tl  e^  1 
of  September  he  was  d  schar<red  uerfertlv  r,,,-, ,    ,,  7 

aflcrwards  a„,l  exlnhkcd  l,im  to  Ihe  llcdin°cl  i,        r  ? 

.;.p,.c<io„„,,„da,,„,,„i,/;,V;\;hi;r 's^ 

he  tame  to  the  hospita  ,  he  had  irre-ul-.r  f,  v,.,         ] 
sweatmg  and  considirahie  con^uUomu' dii^tX,?^! 


IM 


i'J  1I 


!     K    n 


•««#■«     uvvtx 


"  V..V.  .i.iu-urtj,  visit  was  lunerer   nnr  ftirf   «^f 
questions  mteliigentlv      Face  fln^h.^  /'  °"^  f'cJ  not  answer 


Reprinted  fromlhrARCHiVEs"^;M^^^^;i;^-^ 


vii.  No.  2,  April,  1882. 


hi  K  ¥' 


ostii 

JUIfl 

«ligl 

tlio : 
103' 
tcmj 
the- 
wlii( 

WJV8 

at  th 
i.s  thi 
the  t 
very 
more 
of  ri] 
the  e 
ness 

its"] 
iirst  J 
is  nol 
are  8 
have 
onee  ■ 

loSCB, 

Seeor 

theii 

only 

Calv< 

bile  ( 

much 

than 

Oook( 

parts  ,. 

the  larvae. 


I  thoii);,ht  also  at  the  time  that  he  had  some  affection 
of  tlie  apex  of  the  rii,'ht  hin^,  as  there  were  rales  in 
that  rcf^ion.  There  was  universal  ihilness  over  the 
left  side,  with  the  cxreption  of  the  infra-rlavirular 
rc.i,noii,  and  the  usual  physical  sij^nis  of  effusion.  Dr. 
I'enwick  operated  in  the  way  I  have  described  to  you  ; 
the  case  was  dressed  antisepticallv,  and  the  lad  made 
a  remarkably  <,rood  recovery,  lie  entered  the  hospital 
on  the  28th  of  May,  and  on  Julv  23d  he  left  comiilctely 
well,  having  gained  in  tlesh  and  with  the  wound  quite 
healed.  I  exhibited  this  lad  also,  with  the  other  one, 
before  the  Medico-Chirurgical  .Societv,  and  in  both  of 
them  the  result  was  everything  that  could  be  wished. 

CasI'  111.  was  also  under  observation  last  summer 

a  man  named  Clarke,  aged  about  forty-three.  Me  was 
in  the  hospital  for  a  coujjIc  of  weeks  with  pleural  effu- 
sion on  the  right  side.  There  was  irregular  fever,  and 
we  suspected  that  the  tluid  was  probablv  purulent.  On 
iising  the  hypodermic  needle,  we  found  that  there  was 
pus,  and  he  was  treated  in  the  way  I  have  already  de- 
scribed. The  pus  was  drawn  off,  and  antiseptic  dress- 
ings were  applied  every  day  or  everv  second  day,  ac- 
cording to  the  amount  of  the  discharge.  This' man 
was  admitted  April  19  an.l  discharged  [ulv  4,  perfectlv 
well,  having  been  seventy-five  days  in"  hospital.  The 
tube  had  been  removed  several  weeks  before  he  left 
the  hospital,  and  at  the  time  of  his  discharge  the  breath 
sounds  were  audible  at  the  angle  of  the  scapula.  He 
had  improved  in  geneial  health,  and  he  went  back  to 
his  work.  I  saw  him  several  months  afterwards  and 
he  had  kept  well. 

These  three  cases  of  empyema  stand  out  very  dis- 
tinctly in  my  memory,  inasmuch  as  they  are  anion"- 
the  few  instances  in  which  I  have  seen  good  recoveries 
in  this  disease.  It  is  always  regarded  as  an  exceedinglv 
serious  thing  for  a  person  to  have  pus  in  the  plcu'ra'l 
cavity.  The  liability  to  constitutional  disturbance  the 
difticulty  of  gettingthe  suppurating  pleural  membranes 
to  granulate  and  heal,  are  well  known,  and  render  this 
disease  extremely  difficult  to  treat  satisfactorilv.  I  'nder 
the  antiseptic  plan  I  believe  many  of  these  difficulties 
are  obviated.  In  these  cases  the  temiierature  after 
operation,  particul.irly  in  the  man  Clarke  and  in  the 
second  case,  remained  normal,  and  it  would  seem  that 


♦t*"****^ 


*Dle  Parasiten  des  Menschen  Kt,chenmeister  und  zum  2te  Auflage  1881. 


questions  'nU 
dilated.      Pu 

Reprinted  froi 


L.t 


if  tljere  is  no  hlockin- of  ti.e  tul.e.  .hkI  y,a,  .ct  f.ec 
clischarKC  this  disease,  like  an  nrdinniv  abscess  v  en 
reau.d  antiseptically,  will  ^et  perfectly  .dliiMhiK" 

t   rln  ,        'of;  ^""^  '''''   '''-y  ""'<■  '"nstitntional 
ens  II  Dance.     Of  course,  when   \<)u   are  in    nrictico    it 

win   he  d.nicult.;.  you   t..,et  the  complete'' m^^^^^ 
sir^hh   t  v.;  '   ■      '!"  f  >•'"">'  practitioners  it  is  not  dc- 
s  ,ec  ,  I         ^     '   ^'>"^'''''  ""'^'^^  y-H.  devote  yourselves 
speciall)    to  surt(ery.     This  method   must,   from  these 

bl'irlr:'"!  '"  "'"fi"-';^'-"y  '<'  hospital  praJi" 
bu  uheieyon  have  a  case  of  einpveina  vou  can  always 
o  low  out  these  general   rules  :' OV/ ;-/^  .y //,,  ;,^,^;', 

have  excellent  success  in  the  inajoritv  of  cases  of 
enipyema.  A  thorou,d,  withdrawal  of  th'e  pus  is  I  be- 
lieve, essential,  as  wdl  as  thorough  drainage  It  d  cs 
not  appear  to  make  much  difference  whether  you  wall 
ou  the  chest  or  not  with  carbolic  acid  or  iodine  or 
v.ded  you  have  an  effectual  outlet.  If  the  orifice  is 
large,  and  in  a  situation  where  the  drainage  will  be  con 

Hu  'if  von     ^'°  ""'  '''""^  "^^^'''""-  ''-■  -^  "-e-     y. 
15iit  If  you  have  a  narrow   orifice,  you    may   have  to 

make  a  counter-opening,  and  put  in  a  draina'a-.tube 
ioih^S  '^'^ ''"■•-■f^'^'> .  Thil  is  the  method  "^n^y 
lofloncd.   A  drainage-tube  is  put  in  and  the  chest  is 

iodi  T  Thu.:''  '"'"'-"  ""■^"'''^  -'^'-  "'•  -ith  ddute 
vu      ind  f  'r"  ''  r""^  '"■'">'  ^=^^"  ^'-ealed  that 

^^a   ,   and    I   imist  say  that,  excepting  in   the  cases  of 

rare.     It  ,s  notorious  that  the  results  in  manv  instances 
of  empyema   are    most    unfavorable;    several      -ent 
records  of  such  cases  have  surprised  me  bv  tl  ei     li,! 
rate  of  mortality.     One  of  the  best  series  of  cases 

fSon    cltv    H    '•'^ir';'"'  ,•'>'   i^'--  !•  ^■-   I^lake,  of'tl.i 
t^Z^^^^.^  H-spital,'  who,  by    „>eans   of  thorough 
t  ?;^rr  T"-'  "l'^'"'"{.^  I"  the  dependent  portion 

of  the  affecied  side,  was  able  to  cure  thirteen  cases  ou 
o     nineteen    and    two   others   were   verv   gix'  t  v  im 
Moved       Ihese  results  were  obtained  with'out  speci   1 
antiseptic  precautions,  and  I  refer  to  them  with  pie isi'  e 


Hospital  Reports,  ad  Series,  1877. 


.\  n" 

5"Tiro~^^B 

It-     t 

f         ',  4-^          ^ 

1     s 

* 

1 

1    '^ 

1 

"'    '  1 

1 

'  f 

1 

quesl,„„s  .ntelhgently.     Face  flushed,  venules  on  che"ek,  and  mI 

^j!5!f^_Pup»l^sMely^o«^      .ea,     :„  light fopS^hT:! 

Repr-nted  from  the  Archives  of  Medh       "v^I.  vii,  NoTTTATi^Tiiir'' 


H 


13  n 
are 
hav( 
one* 

lOBOt 

Sec( 

the 

Onl;; 

Cal 

bile 

iniK 

thai 

coo] 

parts  of  iM 

the  larvae* 


the  case  ..ualh-  .o'Ln'bad' u/      ^^'  ul!  ess'^'lS;: 
free  open.n-  ,s  niacle.     |„  tl.cse  four  V  ,s  s  th, '  In?  ^ 

?:t.;;£;:ri:  ™-i,,™it  :■''■?"--- 

enough  nifthod,  |,„t  „nc  wliirl,  k     ,^     r.  '^  *""''''-" 

sorted  I,..    Tliereirei     m   ,  ""t  often  enoiiuh  re- 

thecotunry      ;o„ex7hi/i:"'f'\''^''^"^'''''?'''V'''"''^^''"^ 
needle  except  (V  r  n  ,n  o.  .  nf      "'J'"^' .''"•'  'lypoderniic 
of  almost  as  ,n    cl    Zo '. .-  '"'^''l'^^^'''""'  "''^'•■^■as  it  is 

of  .pleural  efT:;;;;;,! ; '  r.;  Sfi;;  cur"""  'r  ^^^^^^^^ 

terior  part  of  the  rl„.J.  """'^""'  i  uiness,  in  the  pos- 
thrust  hehvpolcrni^n;.r''r''1  '''''''  '''^^i'^"'  to 
It  is  so  si„,p,[:  an  o  "a  u  '  hu  U  in'  '""'T"  ^"'^^'^''• 
the  indicatii.ns  y<.,/.'et  f  /  ',  '  h  ""  ''^'™'  ^^''i''^' 
Professor  15 , cell  "  ,f  .'"  ""^    '''  •^''■^■'t^'st  value. 


""jjg  yjL'jjMipM 


*Die  Parasiten  des  Menschen  Ktichenmeistcr  unci  zuni  2te  Auflage  1881. 


in. 


hen  seen  at 
questions  inte 
dilated.      Pu] 

Reprinted  fron 


L.i 


r 


7 

veycl  to  ti.e  car    if  it  i/     ';     !'  '""/'  '"""''''  ^"•<-'  '^-n- 

""t  know,  |,„t  it  has  I      ,  '■'^',"«i"n  -ul.y  it  i,  j  ,|, 

--!llyliconti,e,;,:o':;esic;;'"""'    '^    '"y-X^thcy 
pleura  in  certain  pa's"    Z,     '  ■  u.T    'V'"'    '^'-■'"■'^'^"   '''-' 

'/  >»^'y  Perlora^^  nU  i  J  k  n  t  .  h  ^'"^"^  ""-"  ''^'"^"'. 
tl>e  bronchial  ,„l,es,  Sh7  i^v"]'''^'"'^'^  ''""^'.^'^ 
way.     The  cases  we  have  lA,  H     V'^-  '■'^"'•''^io 

foration  into  tlie  h.n./   n,^l  ''"  ''"^P'tai  of  per- 

i"K^Iy  well.     I)r   &  InV  Ir  i'T'''  ''■'^1'  ''""^  ^■•^''•e.!- 
recovxTcciperfectly/    I  r  wf    n    V'  '"'''   '^"^'-'^   "'"eh 
'relieve,  In  the  u^  rds,    n^    c     Uu':  '  ''''' ^'  ^''''''''• 
li>n«  and  was  disch-n  ^e  I   I  ,     '"  Perforated  the 

perforate  the  diaph  ^^l.^  ,;;';;'^^''"^-  '[  '"^'y  also 
forate  externally  enim  c',,  ,,  ''  '•'  '■}'"■  '^  '"^y  per- 
for  months  or   leave  "*-* '-■^^"■"''*)  <ind  dischar-e 

point  to  be  b  rne  „  n\i  urTn'"'"'  ^'^'''"''^  •'^^^"=^-  A 
Pyema,  when  they  e^iT  to  "  "'?'  "^'e'"^^iclcd  eni- 
!^  that  they  sonie  'i^^  nd^^  '""''r^^,  "^e  surface, 
's  exccedinglv  likely  to  C  .  /■  '^"■'  "'*^  Pulsation 
an  aneurism"  '  I  the  chronir  °  "''"f "''  ""'^  '''^'t  of 
■nebular  fever,  and  he'p""^,S^  .J'-,  P^^'^ents  have 
to  induce  either  amyloiclTJ.?^  r  '''''■^'''"  '^  ''kely 
f  e  .sound  Iun,r  cm  ij  o  ht  ,k^  °/  ^'"-"  "^^^-'^-'s.  or  else 
they  jrct  tuberculous  '^  becomes  affected  and 

Ie.n t  nS'ujKm  th^^^S^^!:;::^  eftusion  whether  puru- 
specin.cn.  which  was  tktn  ?rnn  ^^'  ''^"  '^^"  '"  this 
'"  wl.ich  the  patient  ded  of  \  '"^  '^'''''^  "^  empyema, 
opposite  lun^r  v"^  ^ee  IumI  ,'"'.,  Pr"'"""''-^  «<"  tl'e 
•['  ^^  eake-hke  mass  p?es  eTb  ck  ^  '""«  'f  '^'^'^^'""^ 
the  vertebral  column  ''^'""^'t  the  side  of 


When  seen  at  the  mid-day  visit  was  quieter,  but  did  not  nn« 
quesaons  intelligently.     Face  flushed,  venule    on  cheeks.  7 

Repnnted  from  the  ARcm^^T^T^^^^i^i^l^T^^;!— i;^^^^^ 


1 


I  i  1 1      i 


'.  1  . 

i.    ^ 

'  ' 

■•!■. 

ik    ''■'  ' 

'imf: 

. 

' 

i 

'    1'^' 

'I  ' 

¥ 

1  i 

1 

i 

■    1     fi  ' 

4 

i  J 

as  .r'^ 

till!  r 
103° 
ti'inf 
tlio  1 

atfl 

ia  tfc 

the 


Am 


8 

""n'  tile  ailv  inta;,'cs  of  th 


•-•inpycma  appear  to  he 


e  antiseptic  method 


Ampi 


"lis  iltaina^ 

'2.)    The  avoj.l, 
cases  Mere  the  .lis,  1 
sive. 


I'le  prox  ibion  is  made  for  ft 


<-'o  aiul  conti 


nii- 


"luc  of  putiefa(  t 


i<>"  ;  in  none  of  the 


'■'"Kesui  the  sli^rhtest  degree  offen 


'3.)  Theca 


iind  the  si 


se  with  uhieli  the  oprrati 


<|ueiit  dress 


nail  amount  of  iroiil)| 


m  IS  poifo 


niL;s. 


e  cntaded  in  the  sul 


lined 


)se- 


U-)  The  heaii 


qiiences,  as  annloid 
likely  to  follow.  ' 

Noti\~Ji,/y   //_    -I'll 


I'K'  is  more  ra 


Pi 


11,  and 


uiseasc   and    phth 


serious  conse- 


sis,    arc    1 


ess 


4th.    Hasd 


verj 


except  on  one  cveni 
Ih     " 


ne  lem.ukably  well.     'I 


IJaticnt  operated  ui) 


■ril  day;  discharge  very  sligh 


dressings  ch.ihged 


)n  on  the 
emperature  normal, 


ght. 


now  evcri 


the 
lies 


its 
lire 
is  I 


are 


^v-<^ 


^^^hll^(.^L-J ^   ^//   ///./'^~ ^^l^- 


VY/^-  ToM.'^-^/c^CLu 


7^  rC 


ft. 


*-  C  I.  li 


y      ^ 


/^  iTti. 


t-C 


/^^A  u/.. 


> 


t7 


^4^a/" 


'"f- 


■■'  c^^zz: 


■  1  t.t/'»-» 


'J.^nT^ 


'/ 


1^^« 


— '   »''C.^^^ 


(i^CC^. 


ftu: 


'^'I^^ClUBlB.  • 


*Die  Parasiten  des  Menschen  Kuchenmeister  «„d  zum  2te  Auflage  1881. 


The  chie 

the  syniptc 

ceded  the  a 

anparently  1 

changes  on! 

J.  VV.,  ag, 

was  admitte 

For  past    fi 

taken  a  gocx 

good  health 

got  up  at  nij 

usual.     For 

had  occurrec 

ing  of  the  4t 

though  still  £ 

i-omplaining 

feeling.     In  1 

excited  all  ni 

cessantly  tall 

6th  the  deliri 

hospital.      O 

He  passed  a 

bed.     In  the 

When  seen  at 

questions  inte 

dilated.      V\\\ 

Reprinted  fron 


L.t 


M\ 


mi! 


UREMIC  DELIRIUM  AND  COMA  AT  A  VERY 

EARLY   STAGE   OF    INTERSTITIAL 

NEPHRITIS. 

Bv  WILLIAM  OSLER.  M.D.,  M.R.CP.  LoNn 

PK.P.SSO«  OK  T„.   ..s.„„BS  OK  MHO.C...    Mc  C...  CO..HO..   MONTR.... 

The  chief  points  of  interest  in  this  case  are  •     r.Wh 
the   sy.pto.s  with   dehriun,  ;  (.)  the   nlTa,  "wi^^  w  il"  f 
ceded  the  attack-a  prominent  factor  in  some  instances     mX 
apparently  normal  state  of  the  kidneys,  which  gav"  evident  o 
changes  only  on  microscopical  examination. 

J.  VV.,  aged  44,  a  large,  i)o\verfiiliy-biiilt  man  niKv-,,,  t 

got  up  at  night  to  make  water,  and  he  passed  r.fh  ' 

usual.     For  about  a  week  he  hLd  been  g  "^^J.^^"  T^  ^T 
had  occurred  among  the  men  in  his  department      n:  t  ' 

mg  of  the  4th  h.   had  a  chill,  and  felt  unwelUU  dav      nV'u 
though  still  ailing,  he  went  to  work,  but    et  rn  d  Tnth      .    '  ''^' 
complaining  of  soreness  over  the  wLle  bodv  he^^T  !,"""°" 

feeling.  In  the  evening  he  becamTlSs  .  ''"^ ''^'"^ 
excited  all  night ;  could'not  be  kept  in  bed  but  walH  T'  '"' 
cessantly  talking  and  directing  hfs  ::en1;  ^ttt  ^'Sn  the" 
h     pi  a^^'orad"'"^''  T'  ''  '''  '-'^-^  '-  -"  broug  t    o 

K  ^  T  \  ^  restless  night,  and  was  with  difficultv  kpnf  ;» 
bed.  In  the  morning  (7th)  he  was  quieter;  temperature  1° 
When  seen  at  the  mid-day  visit  was  quieter.  Lut  d^d  not  ansi; 
questions  uUeii.gently.     Face  flushed,  venules  on  cheeks  and 

Repnnted  from  the  AKC^I^^T^ir^i^i^ii;^;^^^^^;;-^^ 


■,ll:' 
1 

■!•■  ,' 

?  -V  i'     ' '  '  i 

<    i-?'  'J'   .'     I     i 


I  .1 


II I  ^1 


if  ■ 


J)    > 


2  ARCHIVES   OF  MEDICINE. 

scopic  exiiniination  of  eyes  negative.  No  special  symptoms  in 
chest  or  abdomen.  No  dropsy,  nor  oedema  of  ankles.  Heart's 
impulse  not  forcible  ;  apex  in  normal  position,  but  difficult  to  feel  ; 
pulse  full  \n  volume,  tension  plus;  radials  not  stiff.  Urine  was 
passed  in  bed  ;  that  drawn  off  with  catheter,  high  colored,  sp. 
gr.  1039,  highly  albuminous,  with  numerous  finely  granular  casts, 
many  of  unusual  length.  Toward  the  afternoon  he  slept.  In 
the  evening  was  very  torpid  ;  did  not  know  his  wife.  Tempera- 
ture normal.  On  the  8th,  after  a  quiet  night,  he  was  very  drowsy, 
roused  with  difficulty;  pulse  120,  temperature  99^^°.  Pupils  of 
medium  size,  react  slowly.  Passed  24  oz.  of  urine  ;  same  char- 
acters as  before  noted.  Toward  the  evening  he  became  deeply 
comatose  ;  the  respirations  increased.  He  was  bled  to  20  oz.,  with 
the  effect  of  reducing  the  rapidity  of  pulse  and  respirations. 
Pupils  dilated  ;  temperature  rose  to  103^°.  Thecoma  increased, 
and  death  took  place  at  3  a.  m.  on  the  9th.  The  treatment  con- 
sisted in  bromides  and  chloral  in  the  early  stage  ;  purgatives, 
pilocarpin,  and  vapor  baths. 

Autopsy. — Brain:    Arachnoid    turbid    at    base    and    over    the 
sulci  ;  much   serosity  about  the  membranes,  which    stripped   off 
very  easily.     Several  slight  ecchymoses    in    gray  matter  of  right 
hemisphere  ;  one  at  top  of  ascending  frontal  gyrus  was  the  size  of 
a  small  i)ea.     Ventricles  contain  a  moderate  quantity  of  fluid  ;  walls 
not  softened.     On  section,  substance  of  the  organ  not  sjjccially 
moist.      The   arteries   at    the    base   not    atheromatous.      Heart 
weighed  382  grammes ;  valves  healthy,  muscle  substance  of  good 
color;  walls  of  left  ventricle  measured  from  15-18  mm.;  cham- 
ber, 8.5  cm.  from  apex   to   aortic   ring.     Aorta  presented  a  few 
scattered  patches  of  atheroma.     Nothing  of  special  note  in  lungs, 
spleen,  stomach,  ox  intestines.     Kidneys:    right,  190  grammes  ;   left, 
175.     Capsules  detach   readily  and  leave  smooth  surfaces;  no- 
where granular.     Organs  cut  with  moderate  firmness  ;  cortices  not 
diminished  ;  medullary  rays  very  distinct  ;    intervening  vascular 
regions  with  the  tufts  injected.     Arteries  at  bases  of  pyramids  not 
unusually  prominent.     Pyramids  look  normal.     Renal  arteries  not 
atheromatous.     Altogether,  the  niacroseopic  appearance  of  the  or- 
gans did  not  appear  to  substantiate  the  diagnosis  of  urjemia  which 
had  been  made.     Beyond  a  slight  increase  in  firmness  the  glands 
certainly  did  not  present  appearances  which  would  have  attracted 
further  attention  had  not  the  symptoms  demanded  it. 

On  microscopical  examination  the  only  striking  change  was  in 
the  Malpighian  tufts,  a  number  of  which  were  found  atrophied  and 


surroandei 
where  the 
a  small  ho 
the  tuft  a]: 
proliferati( 
was  a  very 
about  ever 
atrophied 
rating  the 
trophy  of 
no  hyaline 
where  hea 
there  were 
tubules.     ] 
in   the  inti 
midal  porti 


ORIGINAL   OBSERVATIONS. 


surroanded  by  an  increased  growth  of  fibrous  tissue.  In  some, 
where  the  process  was  far  advanced,  the  tuft  was  converted  into 
a  small  homogeneous  mass,  without  nuclei  ;  in  others,  portions  of 
the  tuft  appeared  normal.  There  did  not  appear  to  be  any  special 
proliferation  of  epitlielial  elements  within  the  capsule,  but  there 
was  a  very  general  thickening  of  the  delicate  zone  of  fibrous  tissue 
about  even  healthy-looking  ones.  In  the  neighborhood  of  several 
atrophied  tufts  there  was  a  small-celled  or  nuclear  growth  sepa- 
rating the  tubules.  The  small  arteries  presented  decided  hyper- 
trophy of  the  muscle  elements,  particularly  in  the  circular  coat  ; 
no  hyaline  degeneration  of  the  intima.  The  epithelium  was  every- 
where healthy-looking,  distinctly  granular,  but  not  swollen ;  and 
there  were  no  collections  of  epithelial  ^//^J/vV  observed  in  any  of  the 
tubules.  Except  in  the  vicinity  of  the  atrophied  tufts  no  increase 
in  the  intertubular  connective  tissue  was  noticed.  In  the  pyra- 
midal portion  some  of  the  tubules  presented  finely  granular  casts. 


m  • 


. 

f 


Parasite 


Bi 


(From  Can 


i 


jufj 


—       'V 


ON  CP]RTA1N 

Parasites  in  the  ttloocl  of  the  Fro 

Bv  WILLIAM  OSLEIi,  M.  D. 


g 


(From  Cana,i;,n,  Natnrullsf. 


^''•I-  X,  No.  7.; 


jii  ■ 


*li 


s  ; 


(  ?i  f 


(I'n 


IN  TH 


Fellow  of  the  1! 
seopical  Soo 
iMcUill  Univi 

Tq  my  Pra 

whilf  the  St 
{Rana  Mitg'u 
body  like  ii 
which  liad  uot 
water  on  the 
slides  of  sevei 
to  it,  ami  I  n 
description  :— 
triangular  in 
narrow  oiul  is 
a  broad  band 
aD<;;le  is  prol 
dulatitiii'  l'rin< 
the  appearanc 
other,  the  wc 
and  tenuity  u 


Rea 


(From  CitihuHaii  Naturatist.      IW.  .V,  .\'.'.  7 J 


ON  CERTAIN  PARASITES 
IN  THE  BLOOD  OF  THE  FROG.* 


By  William  Oslei!,  M.I).,  M.li.C.l',.  L(im.. 

Fellow  of  the  l!(>.viil  Microscupiciil  Society  of  London.  I'lc^^iilent  of  tlie  Mijn- 
soopiciil  Soeiet.v  of  Montreiil,  I'idfessor  of  tlio  In^titntes  of  MoilieinL', 
McOill  University. 

Tn  my  Practical  Histology  cla.^s,  duiiiio- tho  winter  of  1881-82, 
while  tiie  studeut.s  were  working  at  tiie  blood  of  the  froo; 
(Raiia  Mugicm),  I  noticed  in  one  of  the  .slides  a  remarkable 
body  like  a  flagellate  infu.-orian.  I  thought  that  it  was  one 
which  had  got  into  the  blood  at  the  time  of  withdrawal,  from  the 
water  on  the  web  of  the  foot.  Meeting  with  examples  in  the 
slides  of  .several  other  student.^,  my  attention  was  again  directed 
to  it,  and  I  made  .several  .sketches  and  wrote  down  the  foUowini; 
description  :— "  Finely  granular  protoplasmic  body,  somewhat 
triangular  in  shape,  about  the  size  of  a  colorless  corpuscle.  The 
narrow  end  is  prolonged  into  a  eilium,  while  the  other  presents 
a  broad  band  of  rapidly  undulating  protopl'ism,  which  at  one 
angle  is  prolonged  into  a  long  la.sh-like  process.  The  un- 
dulating fringe  and  the  cilia  are  in  constant  motion,  iiivin" 
the  ap|iearance  o'"  rapid  waves  pa.^sing  from  one  corner  to  the 
other,  the  waves  of  protoplasm  gradually  increasing  in  length 
and  tenuity  until  they  have  the  appearance  of  projecting  cilia. 


*  Read  before  the  Montreal  Miemsioiijial  Soeictv. 


•;■  f  '■' 

i 

0   ! 
V  . 

A 


f 


No  nucleus  ciui  bo  M Tlmuuli  iu  (-oiistant  iictiou  no  change  of 

locality  t.ikos  place."      Fi-    I. 


projection   ai 
continued    to 


(»iMo.)l<iii-  up  the  Mibj.'ct  [  t'.M.ii,]  tli.it  the  little  organism  was 
the  'fn/jhiuosowu  saiujiilnis  which  IkhI  been  described  ori-iuully 
by  Gruby  as  an  entozoon  in  the  blood  of  fVo-s.  and  by  Ray 
Lanivoster  (not  at  tiie  time  knowin-  Gruby's  observations)  as 
rii(Iii/i,i,i,  the  type  of  a  new  -roup  of  Ii-fusoria. 

Thoutrh  a  triflin-  litth:  object  it  possesses  considerable  interest 
as  there  is  still  a  doubt  concirnin-  its  real  nature  and  the  P^ove- 
niont  wiiich  it  displays  is  unusual,  beino-  ..either  the  slow,  creep- 
in-  riiizopodal  motion,  nor  yet  truly  ciliary.    Minute  protoplasmic 
<n-anisms  usually  di.sph.y  one  or  other  of  these  types  of  move- 
ment, but  in  the  object  under  consideration,  there  is  a  peculiar 
wavy  undulation  aloii-  one  mar-in  of  the  creature  too-ether  with 
a  lu,shino.  vibratile  action.     Studyin-  the  mar-in  under  a  hi-h 
power  a  rapidly  succeeding  series  of  waves  is  seen  to  pass  from 
one  side  to  the  other,  increasing  in  length  until  at  one  corner  the 
wave  IS  extended  into  a  lengthened  eilium  resembling  the  whip- 
like    Hagellum   of  an    infusorian.       In    the  specimens    which  I 
examined  the  undulations  always  passed  in  one  direction  and  it 
appeared  as  if  from  the  tips  of  any  of  the  waves  the  protoplasm 
could  be  extended  into  cilia,  though  usually  only  those  at  one 
end  i.resented  them.     It  is  this  latter  feature,  together  with  the 
peculiar  wavy  character  of  the  motion  that  -ives  the  creature  a 
special  interest  and  makes   it  quite  an  exceptional  one  amon- 
organisms  of  its  class.     A  fine  hair-like  extension  from  tlie  nai" 
row  end  was  also  in  constant  motion  and  appeared  to  vary  con- 
siderably in  length,  as  if  it  were  only  a  delicate  process  of  the 
protoplasm,  and,  unlike  a  true  rUium,  capable  of  elongation  or 
retraction.    I  kept  one  under  ob.servation  for  over  an  hour,  durin- 
which  time  the  movements  kept  up,  but  got  slower  towards  the 
close.     Ihe  undulatory  motion   at   last  ceased,  but  the  tail-like 


and  were  evic 

the  view  that 

porary    exten 

manner   in    w 

til  at  they  wer 

or  of  various 

"a  mouthlcss 

however,  it  di 

generally  in  p 

sitic  entozoon, 

dent  organisr 

freely.     Dr.  C 

concerning  thi 

transformatioi 

the  warm  stag 

pu.sele  into  th 

place  by  the  d 

a   rapidly  und 

types  of  tliesi 

"  Kymatocytes 

condition.      I  1 

but  without  si; 

deal  iicre  with 

which  have  yci 

the  blood  of  m^ 

not  found  then 

This  session 

tology  class  to 

corpu,scle  in  thi 

•Mieroj 
tA 


projection   nn<]   th,.   f1;.ovlluiii   at,   tlu'   inai-in  of  tlio  broad  end 
contitiuod    to  ,ii,)V(!    (tlie  Mppoaraiicf   is   represented   at   H-,'.  2.) 


and  were  evident  alter   motion   had   eeas^d.     Ti.is  would  iavor 
the  view  that  these  processes  were  '■  eilia."  and  not  merely  tem- 
porary   extensions    of   the   protoplasm,    thou-li    tiio   remarkable 
manner   in    which   the  eilia    were  extended  and  retracted  shows 
that  they  were  not  similar  in  all  resprets  to  the  cilia  of  Infusoria 
or  of  various  animal  cells,      l^rotessor  Lankester  speaks  of  it  as 
"a  mouthless  infusorian.  clos,>|y  allied  to  Opalinidiv?,  from  which 
however,  it  difters  essentially,  as  well  as  f,„ni  In/nsono  cillnta 
generally  in  possessing  no  eilia."     (^,ruby  described  it  as  a  para- 
sitic cntozoon,  while  Siei,old  -  states  that  it  is  not  an    indepen- 
dent or-auism,  but   simply  an   undulatin-  membrane  .swimiug 
freely.      Dr.  Gaule  f  lias  advanced    some   rather  Htartlins;  views 
concerning  this  little  body  which  lie  believes  originates  in, ""or  is  a 
transformation  of  a  colorless  blood  cospuscle.     He  states  that  on 
the  warm  stage  the  proces,s  of  conversion  of  tlic  wliite  blood  cor- 
pu.selo  into  the  I'ri/pxiwmmu  may  be  readily  followed  and  takes 
place  by  the  development  at  one  margin  of  a  vibratile  cilium  and 
a   rapidly  undulating  membrane.     He   recognized  four  or  five 
types  of  these   transformed    blood   corpuscles   and   calls    them 
"  Kymatocytes."     They  may  return  to  their  original  corpuscular 
condition.      I  have  tried  to  Ibllow   these  observations  of  Gaule 
but  without  success  and  adhere  to  tli      pinion  that   we   liave  to 
deal  iiere  with  a  minute  parasite,  the  alHnities  and  life  history  of 
which  have  yet  to  be  worked  out.     They  were  not  abundant  in 
the  blood  of  my  frogs  and  were  only  met  with  in  two.     I  have 
not  found  them  this  season  in  any  of  the  frogs  in  my  tanks. 

This  session  my  attention  was  called  by  a  njember  of  my  His- 
tology class  to  what  he  thought  was  a  peculiarly  elongated  white 
corpuscle  in  the  frog's  blood,  but  which  I  recognized  as  another 


»  Micrographie  Dictionary— Undulating  Membranes. 
t  Anh.  f.  Anat.  u.  Physiol.  (I'liy.  Aht.)  18S0. 


^ 


•  ii.;  '   i 


ii' 


■h»/ 


ir 


tM 


H 


I.  * 


if 


parasitic  Ibrm.  Tin;  bluod  cxriiniiicil  by  llie  .stuilcDt  on  that  day 
was  taken  IVoin  two  bull  IV.. us  (/»'-/„,/  Mii;jirns).  hnt  only  ono 
contained  the  jcira.sitcs.  'J'jic  (iri^anisni  presents  tin;  roliowinj? 
characters: — Body  an  elongated  (iv.ij,  saus:i,t;c-shaped,  ends  coni- 
cal, one  sonictiuips  narrow  and  prol()nj;ed.  licni^th  somewhat 
more  tii;ui  h:ilf'a  red  eorpiisele,  Tlie  protoplasm  is  iiomogeneous 
and  more  translucent  tli,,n  tint  of  colorless  corpuscles  and  shows 
two  or  more  -mall  central  vacuoles  (?)  with  a  lew  ,u:ranuk\s. 
Movements  slow  and  creeping,  accompanied  by  ;ai  occasional 
bend  or  twist  of  the  body,  uo  on  at  ordinary  temperature  ;  a 
little  accelerat.d  but  not  altered  in  character  on  the  warm  sta>;e. 
The  tail-like  end  tliou-li  prcidne  ,1  ,|,u.s  not  lerminato  in  aeilium 
Fii. 


the  kidney  < 
on  the  addi 
a  number  o 
very  clearly. 
tioii  to  the  ] 


In  blood  fi 
te  seen  well 
pusclc  with  ( 
five  times,  ai 
and  r.  This 
and  did  not  s 
sen  ting  no  tra 


« 


^^ 


seen 


tl.e  kKlnoy  of  the  ^,•o,,^  Witim,  th,  r.\U  tl.ey  e.in  best  be  se... 
on  tlie  ad.htion  of  salt  ...ihaion  ;{  .  I  l„iv..  \\nvu].  after  tryin" 
a  number  of  solutions,  tl,,,t  I'iloeirpin  •  bri,,^.  them  ou't 
very  cloMrly.  In  one  fro-  tlir  i..<l  .•orpuseles  eontaineJ,  in  addi- 
tion  to  tlie  Drep:mi.lia.  sni:iller  irr.-ul.ir  musses,  ti-  4. 


In  blood  f.om  a  smnll  fn-  il,„v  uv,,.  wry  .-.bundant,  and  could 
be  seen  well  without  .my  re„.,ent.  Kiu,  5  „  vepresents  a  cor- 
puscle with  one  inside  whi.-L  fr,,v(l|,..l  r.mn.l  tl..'  cell  four  or 
five  times,  and  then   miuT.ted   fn^n.   it  ;,s  shown   :it   Fi-s.   5  b 

andr.     This  curious  ),li,. „n.ii   w,,s  witnessed   severaf times 

and  did  not  seem  to  injnre  the  .•or,u,M.les  very  much,  some  pre- 
senting no  trace  of  the  ,,„int  „r  .xi,.  „th.Ms  a  slight  depression. 


Hi'   I 


M 


i 


r^ 


ON  C 


II!  r 


The  l'„ly 

.111  I'xcec'diiij, 

sive  tlishibii 

ancc  iiiid  iii't 

♦liiy  ll.iVO  ;it 

while   tlu:  v\ 

'onus  iiifike  i 

with  thi'  ()iih 

witii  the  hjd 

i"    1855,   thi 

1830,  wiis  tli( 

to  the  whole  ( 

division  of  tin; 

Bi-iichiopods 

the  divi.siiKi   } 

into  two  order 

are  arr!in,<;ed  i 

are  provided  m 

llol0Clliiit;|,  ill  w 

tliroat    is   not 
there  are  three 
almost  all   the 
Lophopcii  into 
iiiatellidio — ill  i 
tised,     The -en 
we  know  at  pre; 
and  the  five  spc 

As  I  have  n 
I  .shall  proceed  t 
and  li/b  history  c 
on  the  table  be 
two  terms  whiel 
The  term  acnm 
system  and  solid 


•Rea 


(From  Canadian  Naturalist.      l\ 


'/•  .\-.  .\^, 


J 


L 


III 


ON  CANADIAN   FUKSII-WaTKH    POI.VZOA.  =i= 

"v   Wii.r.MM  Osf.Kit,   Al.l). 

;- 1855.  u.i.  ,J.,il  .J  ::,. . Lf-^^  'V"v  %1 ''  ^^^-• 

ISJJO,  w.s  tlio  fir.t  to  se„..r-.f..  M  ,^'-  "J-  ^  •  Thompson,  ]„ 

to  tl,e  whol..  el.ss,     1         :    /  T'"  "'      '?''''^  ''^'  """•^  ''"'^-» 

ti>eaivi.o„Mo,,u.oi,:-;;^^':;^:'''-,:-;;;;'^'^.- 

int..  two  „,,1„|,,  ;„   II     .,,    I  "  '  I  "Iy2'»  «i-»  .livi,l,.J 

"■■""lli.l..^-i..  .1...  li.n„c.,-  ,1,..  .,„i,    I  ;,"""''■■"  "'"'  "'"  '■<»- 

;d...o«.ipee::';;ii'rr:,:x-';:™^';«™..ii... 
i>i.»ii^^::ar:;:i::L"!::,::r:„:S"*"^'r'^™"-- 

*  Read 


I 


m  ,  , 


'1 

■     1                                ^ 

!  1 

cilli'il  till'  I'ctncyst,  the  iiit'Tll 'il  tin'  t'ii(l(i('n>t,    iinl  tlii'  liorsi'  .xlioo 
sli;i|i('(l  (|i>k  >ii|)|iiirtiii_;  till'  ti'iilacli's  till'  li>fthiif)h<tri — strictly  tin; 


ill 


Till-  lii'st 


hcirrr  ot  till'  |ihiiii('.  I  III-  lii'sf  sjK't'ii's  tn  wliieli  I  will  direct 
yi>iir  attciitioii  is  tin'  I'l rtiimlfl/ii  m'Hjiiifv'i  iil'  Lcidy,  dcscribcii 
by  liiin  in  the  |ir(i('i'rdiii._'s  of  the  Acidciiiy  <il'  Scii'iic'  of  I'liila- 
(li'lpliii.  t'lir  Nov..  IS')!,  .111(1  (li'fliu'd  ,is  I'oliow.s;  —  Civnivitmn 
ina.'Hsivc.  lii'lntinoii],  liyiilinc,  tixi'ii,  iiivostiiiu  builios.  Orilieo.s 
ariMiiijod  ill  irrciiiil  ir  lnhitc  Mrcdltc  npnii  llio  i'vw  siirl'iK^o.  fiO- 
|)ho|iliorc  crcsoi'iitic.  Ov.i  iciiticiilir,  witli  .in  .iniiiilus  ind  m.ir- 
irin.il  opines.  The  specimens  ;)m  ijie  tahle  slmw  well  tlie  liyujino 
uelatinons  nature  of  tlie  roiKirimn  and  tho  arranp'inent  (if  the 
Polyps  upon  the  surface.  This  is  jieriiaps  tlie  most  .ibuiidint  fresh- 
water I'oiyzdon  in  the  country,  heini;'  found  in  the  (iiiint  watcr.s 
about  tho  mouths  (if  the  niiin' nms  stre.mis,  ,ind  in  tho  .small  lakes. 
It  is  not  very  .ibuiul.int  in  Quiibec,  but  it  has  been  found  ne.ir 
St.  Andrews,  and  I  oht.iined  a  beautiful  spi'cimeii  from  Ijako 
Memphremau'oir.  I  iiave  iu)t  seen  it  in  the  neiiihborhood  of 
Montreal.  This  species  ]irefers  i|uiet.  still  waters,  not  too  much 
exposed,  nor  of  l:iri;e  extent  and  subject  to  commotion  from 
waves.  Thus  I  have  never  found  it  in  Lake  Ontario  itself, 
but  always  in  little  sheltered  iiKn>hy  bays,  where  it  is  found 
encru.stinj,'  ious,  uprij;ht  sticks,  and  the  stems  of  ru>hes.  My 
attention  was  early  directed  to  this  form  as  it  exist.s  iti  extraor- 
dinary profusion  in  the  Desjunlin  can.il,  whicli  leads  from  Bur- 
lington Bay  to  my  native  town  Dundas.  The  wooden  sides  of  the 
canal  ba^in  in  the  months  of  July  and  August  are  almost  uni- 
formly covered  with  this  m.iunificent  species.  The  growth  bejj;ins 
about  IJ  to  2  feet  below  the  surface  and  extends  in  depth  i'or 
the  sanij  distance  or  even  further,  rarely,  however,  deeper  than 
six  feet.  The  mas.ses  form  extensive  .sheets  usually  a  few 
inches  in  thickness,  or  el.sc  beautiful  symmetrical  projections,  ()-12 
inches  in  thickness,  which  spring-  either  from  a  bed  of  l>lie  Polyps 
or  are  i.solated.  In  the  summer  of  1S(J7,  durinii'  a  visit  of  my 
friend,  tho  Rev.  W.  A.  Johnson,  of  Weston,  I  showed  him  tin,' 
masses,  and  we  airreed  to  subject  them  to  examination  with  the 
microscope,  not  haviiii,'  any  idea  as  to  their  real  nature.  Jud^'c 
of  our  deliiiht  when  we  found  the  whole  .-urface  of  the  jelly  was 
compo.''ed  of  ,i  collection  of  tiny  animals  of  surpa.ssiiig  beauty, 
each  of  which  thrust  out  to  our  view  in  the  zoophyte  trough  a 
cresceat-shaped  crown  of  tentacles.  Recognizing  it  as  a  I'olyp 
we  were  greatly  exercised  as  to   its  po.^itiuii,  piesentiug  as  it  did 


in    tlu!   met 

MpecicN      do 

in   the    Am 

Alplieus  Hj 

course  of  pii 

On  exaniini 

are  >een  to 

areolju,   whi 

a.ssume  hex. 

lar  areas  tin 

occupied.     \ 

tentacles  giv 

entirely  disa 

This  species 

polyps  over  c 

tation.  Thee 

tentacles  are 

tho  thro.it.gl 

the  areoiaj,  w 

at  various  st; 

the  den.se  a^' 

gelatinous  nii 

of  the  polyps 

ing  to  the  an 

a    radi.ite    m; 

often  a  reddi." 

the  {iresenee  ( 

present  a  jelli 

the  developmc 

excretion  or  h( 

depends.      \V| 

colloidal  proje 

rushes  the  mo 

fore  you  gives 

I  have  meaMii 

which   was    1- 

weight  [)  lbs. 

ofthc.se  creatu 

the  marsh  on  ( 

through  the  1 

would  not  go  i 


1  > 


in   tlu)   .....tluMl   of  ^nnvlli,  m.c!.    variation   IVo.u    ihc    .,nli„ary 
Hproi...    ,lt..scribe.l     m    .,ur    zunl„.i.,..l     ,,.xt    b.-uks.        H.mnily 
m   11...    AnM.ri.,.M    Nutunii.t    lur   ,|..t   y  ,r   vvc    .net    witl.   M." 
AlplKMis  llyati's  p,,H.rs   „„    tl,.    l'n.si,.vv,,t.,.r    l'nl;yzoa.    then    in 
o.nn>..  .,1  ,,ubiu;:.ti..„,  an.l  obt  anud    lull    inr.mnatio.,  thnvtVu,,. 
On..xannnin-thcsurf:.L-o..ra   mans  ol'  iVctinatulla  ib,,  p„lyp,' 
are  >ee,.  to  bo  arran;;..,!,  an  .ee„  in  tl.r  spirit  |.rfpa.atimi.  in  cl,..se 
arooiic,   wbich,    bein-  crowded   and  enuipre.sed    lonetbcr,  oft.Mi 
assume  bex,..onal  outlines.      K.on,  tiie  peripbery  of  these  inx-u- 
lar  areas  the  polyps  project,  the  central  part   bein-  as  a  rule  un- 
oceupu.,1.     When  in  the  water  the  pn.trusiun  of  .!„.  innumerable 
tentacles  ^ives  a  fine  velvety   appe,.r,u.cc  to   the  surlaee,  which 
entirely  disappears  on  tonebin-  the  polyps  or  ai-it.tinj.  the  water 
This  species  is,  bowver,  much  less  timid  than  >ome  others,  and  tbo 
polyps  ov.T  even  a  small  ma.s>  do  not  all  withdraw  on  a  >li  .ht  irri- 
tation. The  color  nnhepolypidom  is  .li,,btb,.,wn,  or  when'thctcn- 
tent.cles  arc  extended,  ,,  faint  rosy  ,vd  hue,  due  to  the  color  about 

the  throat., i;limmerin,utbr..uuh  them.   Towards  the  central  part  of 
the  areola..,  white,  bn.wn  and  dark  >pots  are  .seen,  reprcscntinjr  ovul 
at  various  sta,;;es  of  development.     The  ce  ajecium  composed   of 
the  den.sc  a-re;:ation  .d' polyps  j.s  closely  united  to  the  subj.ccnt 
gelatinous  mass,  which  con>litutes  here  theectocyst.    On  removal 
of  the  p„lyps  the  surface  ol'  the  jelly  presents  patterns  eorre.spond- 
in-to  the  arr.n^^:nicnt  of  the  .u.imal.s,  irregular  areas  jrrooved  in 
a    radi.ite    manne,.      Tin-  superliciul  portion  of  the  ectocyst  has 
often  a  reddi.si,  tint,  and  the  deeper  p,,rts  .slightly  greenish  from 
the  presence  of  a  confervoid  -rowth.      .M  ,„y  m  isses  ,d'  lai-e  size 
present  a  jelly  perfectly  eolorlos  ;.nd   pire  throughout,  '"upon 
the  development  ol  thi.s  jelly,  ^hieb  is  to  b.^  regarded  as  a  d..|inite 
excretion  or  secretion  from  the  animal,  the  size  of  the  polyp  „,:,.ses 
depends.      Wjien  encru>tin-  boards    they    are  usually  fl.t,  lar'cr 
conoidal  projection,  uccurrin.i;  at  intervals.     Around  the  steins^of 
ru.shcs  the  mu^l  beautiful  masses  are  found.      The  .small  one  be- 
fore you  ^ivcs  a  ,uood  idea  of  the  -rac^.iul  symmetry  of  the  growth. 
I  have  measurements  of  such  a  .symmetrical  cluster  about'  a  reed 
which    wa.s    14  inches  in   lenjith   and   10  in  circumference,  the 
wci-ht  9  lbs.     In  .some  .seasons  the  luxuriousness  of  the  ..rowth 
ofthe.se  creatures  is  extraordinary.     I,,  the  still  ,juiet  w.'.ter  in 
the  marsh  on  either  side  of   Desjardin  canal,  just  before  it  pas.ses 
through   the  Burlington  lieigbts,  I  have  met  with  masses  which 
would  not  ;;o  itilu  a  Daii.      The  lar-cst   I 


pan. 


lave  ever  seen 


iiy  at 


m 


.5 


m 


1  n 


it'    " 


j  , 

'1 

i  ^  '1 

'H' 

M  " 

^'  ( 


'/ ,,  — 


I 


I  '-am  \, 


tlic  bnttdiii  in  about  nine  j'l'ct  of  water.  I  coiilil  liardly  believe 
it  was  a  mass  nf  jjolyps,  but,  to  satisfy  my  curiosity,  I  stripped 
and  went  in  lor  it.  With  tlie  greatest  ilifiiculty  I  brought  it 
lip  in  my  arms,  but  coukl  not  yet  it  out  of  tiie  water  for  tlic 
weight,  wliieii  must  have  been  close  upon  25  lbs.  It  resembled 
ill  form  one  of  those  beautiful  mas.-es  known  as  brain  coral. 

On  account  of  the  colorless  natuio  of  the  cctocyst  and    the  ex- 
tent to  which  the  polyps  jirotriide.  this  sjieeies  i,s  the  most  favor- 
.ible  to  study  the  j;eneral  arraiij;emenrs  of  the  oruaiis,  the  perfect 
transparency  allowing-  every  detiil    in    the   .structure  to   be  seen. 
I  have  found  it  best  to  cut  a    thin  vertical  slice    lr(nn    the    m.iss, 
containiiiii'  on    the    surface   nut   more    than   one    or    two   rows  of 
jiolyps,  and  eximine   in    the  zoopliyte   tiouLvh   with  a  liall-inch 
U'lass.     It  is  niueh  e.isier  in  this  w  ly  to  obtain  a  view  of  the  com- 
plete animal  tli.in    in   the    livt'   box.      Tlu;    shock  of  the   .section 
and  removal    to    tin'    trouuh    causes    complete    retraction   of  the 
polyp.s.  and  the  surface  of  the  cirnoccium  look.s  smooth,  or  presents 
only  slight  tuberous  elevations.  corres|ioiidin,ii'  to  the  situation  of 
tlie  orifices.      On  watchim:' one  oi'  these,  the   sphincter  closino-it 
may  be   seen    to   relax,  and    the  end.s  of  tiie    tentacles   protrude 
through  the  orifice,  feelinu'  about  from  side  to  side  as  if  to  ascer- 
tiin  whether  the  '-coast  was  clear."     Findill^■  no  cause  for  alarm, 
the  relaxation  of  the  sphineter  proceeds,  the  tentacles  are  pushed 
out   still   further,  resultinii'   ^it  1  ist   in    the  complete  evauination 
of  the  polyp.     The  beautiful  cre.-centic  tul't  i.s  arranued   in   the 
Ibrm  of  a  horse  .shoe,  or  the  letter  U  inverted,  the  tentacles  sprinii' 
from  each  side  of  the  summit  of  the  double  outline,  tlie    mouth 
being'  at  base.      The  number  of  the  tentacles  ranges  from  50-SO  • 
they  arc  siguioid  in  outline  and   incrca.se  sliulitly  in   leii<;th  at 
the  extremities  of  the  arms.      The   inner   rows  incline   towards 
each  other,  the  outei  curve  -racelully  in   the  opposite  direction. 
The  surface  of  the  tentacles   is  covered  with  cilia,  whicii  are  in 
constant  motion,   creatin-  a   vortex,  at   tlie  apex   of  which   the 
mouth   is  situated.     The   tentacles  act  ";;  ,  oendently  as  well  as 
in  concert,  and  thrust   and  bend  in  an     d,i    jtion,  pushinir  away 
objectionable  matters  whicii  may  have  ijot  into  the  throat,  or  are 
present  in  the  nei-^hbourhood.     Frequently  one  of  the  larne  infu- 
soria comini;  within--  the  vortex  is  carried  down  and  attemptinti  to 
escape  is  prevented  by  the  interlacement  of   the   tentacles  whicii 
bendinjr  over  form  a  ea-e.      The   sensitiveness  of  these   ciliated 
arms  is  cxtremo  and  tlirou-h  them  the  creature  obtains  warninn' 
of  upproacliing  danger,,  and  instantly  withdraws  itself. 


From  her 

liangs,  whic 

epistome,   a 

oc.sopha^nis  ( 

The  epist 

the  inner  an 

tection  for  t 

can  be  readi 

appears  to  k 

entrance  of  i 

with  cilia. 

a  dark  i-o-e-r 

animals.     \ 

the  (osophau'i 

dosi'end-:. 

stomach,  into 

expelled  by  t 

The  stoma 

food  is  subjec 

cess   of  di^.es 

cells  upon  the 

Prof.  Allman 

coccuni  is  a  sin 

;ind  placed  pa 

imm<  liately  I 

ol'  the  food  i.s 

tends  the  intcf 

walls  and  earn 

From    the   lov 

funiculus,  ext 

noeciuni. 

There   is  n( 
colorless  fluid  1 
gastric  cavity, 
of  the  eoena'cii 
by  the  small  p; 

llespinition 
tentacles,  but 
sliuiit. 

The  nervous 
by  a    definite  < 


fl 


Kron.  beneath  the  eroscontic  lophophore  the  aliincntary  cnn.l 
l..m,^s.  winch  presents  the  tollowin.  p,.rts  for  observation  :  the 
epistmne,  a  valve-hke  projection  overhauui,..  the  mouth  the 
oesopha^nis  or  throat.  (!,,■  sioniaeh.  intestine  and  anu. 

1  he  ep.stome  is  a   ton.n.-iike  „r.an  arising  at  the  junction  of 
ho  inner  arn.s  of  the   lo,,h.,phu,.e,  .-o,,!  s.rv.s  as  a  valvular  pro- 
tccfon  for  the  n.outh.      It  poss,.>ses  a  .  t  „r  n.uscles  by  whie  ,  it 
can  be  road.ly  n.ove.l  ,.n,l  ,i,.rks  u,,  ,.„„|  ,1,,.,,  .,,,,  ,      ;„.,        j^ 
appears  to  keep  ma,..n.l.,n   the  rhn.t  r.th.r  than  prevent  the 
-;  ranee  ot  anytlunj,  obnuxiou.     J.ke  the  tentacles  it  is  covered 
w.  h  c,ha.     All  t  e  parts  about  the  region  of  the  espi.tome  have 
a  dark  m^e-red  color,  and  this  oi.os  a  peculiar  b,illi,,ncy  to  the 
■mnnals.      A  sonu.what  funnel-shaped  mouth    h.ads  direetlv  into 
tin'  .osopha..us.  a  short  colorless  tube,  which  widens  sle-hti;  as  it 
•leseeu.k       A    valve-like    construction    sep  .rates    it    from    the 
st.nnach,nto  winch,  as  soon  as  the  ,.sopha,us  is  fnll,  the  food  is 
expelled  by  the  contraction  of  the  muscular  walls 

Th;  ston.ach  forms  an  elonuated   tubular  cavity  in  which  the 
^-od  IS  snb,ect    to    a    constant  peristaltic  action   durin..  the  pro- 
eossof    dto^stlen.       The    linin.   membrane    is  plicated   and   the 
«  ^  upon  the  lolds  are  of  a  brown  color,  containing  a  fluid  which 
P.of.  Allman   regards  as  a  biliary  secretion.     The  intestine  or 
ccun,  ,sa  short  broad  cavity  separated  iVom  stonaach  by  a  valve 
;'-i  P  -ed  parallel  to  the  oesophagus,  openin.  by  an  a.nl  oriiice 
";';;"';;'f<  y  '-.eath   the   lopl.ophore.      The   undiuested   residue 
"f  the    ood  ,s  gradually  pushed  through  the  coecal  valve  and  dis- 
nuls  the  tntesttne  and  is  expelled  by  the  contraction  of  the  ceecal 
^.ais  and  carried  away  by  the  action  of  the  cilia  of  the  tentacles 
I<rom    the   lower   part  of  the  stomach  a  cord-like   proces.s,   th^ 
f»"K'ulus,  ..xtends.  and  connects  it  with   the  bottom   of  the  coe- 
noecium.  ^ 

There  is  no  definite  circulatory  systen.  in  the  I'oly.oa.  A 
colorless  flunl  bathes  the  interior  of  the  ca>ncoecium  and  the  pcri- 
^nc  cavity.  By  the  action  of  the  cilia  which  line  the  interior 
of  the  ca.na>c,um  currents  .are  created  which  are  rendered  evident 
by  the  small  pariicles  carried  round. 

Rcspirat^^on  is  probably  carried  on  by  the  cilia  coverin..'  the 
tentacles,    but    our    knowled-,.    of   tl,;.    c       .•  '" 

,ji„,|,j  ^'     '-''    "'    *'"^"    function    IS    extremely 

The  nervous  8y,stem  of  the  fresh-water  Polyzoa  is  rcnres,, 

a     defiint.e    irnno'li.^.i    ,.,k;,.i,     l:.      •        ..  ...  '  ' 


by  a    definite  <fangli 


on  which    lie 


nted 
ill   the  neighborhood  of  the 


J     ■' 


I  V 


W  I 


M:W 


'  hil 


i  i 


Hi 


■I 


hi 


6 

oesnpli.ijxus,  iiuiiiedialely  bilow  tlio  opistomc.  Tt  is  ea>ily  scon  in 
Pectiiiatulla  and  prc-ents  curious  contractions  and  expansions. 
By  tlietro  tlic  [.'osition  of  the  iua.><s  is  altered,  sometimes  approucli- 
inp-  neaier  tiic  (csiijiliijius,  at  otlur.-  beiiiji'  in  liie  lioilow  of  the 
epistome.  >'i  rve  blanches  may  be  seen  jnoctHdin^-  from  this 
paniriion  cliiefiy  towards  tiie  epistomt'  and  tentacKis. 

Tlie  muscular  systiin  is  well  developt'd  and  the  muscles  form 
either  sphincteis  or  elonuated  bi  anches.  \  definite  sphincter 
surrounds  the  orifices  of  the  coena'cium  and  closes  them  lightly 
when  the  polyps  are  retracted,  relaxiiiii;  again  for  their  pro- 
trusion. The  longitudinal  bands  arise  from  the  base  of  the 
ccenoccium,  and  parsing  up  are  distributed  in  three  different 
localities,  on  the  stomach,  the  base  of  the  lophophore.  and  the 
tentacles,  and  are  called  respectively  the  gastric,  lophophoric 
and  brachial  retractions.  By  the  action  of  these  muscles  the 
little  animal  can  be  instantaneously  withdrawn,  and  the  sphincter 
closing  effectually  shields  them  from  injury  and  attack.  Other 
muscles  are  described  by  Hyatt  and  Allman,  in  connection  with 
the  epistome  and  endocyst. 

The  Phylactoloemata  are  reproduced  by  budding  and  true  ovu- 
hition.  From  the  side  of  the  polyps  buds  arise  which  develope 
into  mature  Ibrms  and  in  this  way  the  colonies  are  increased. 
Another  method  of  budding  results  in  the  production  ot  free 
"emmic  or  statoblasts,  which  arise  from  the  funiculus.  These 
present  a  horny  sheath,  usually  dark  brown  in  colour,  and 
an  annulus  or  margin,  which  in  some  species  is  provided  with 
spines.  In  Pectinatella,  the  spines  number  from  12-20,  in 
Cristatella  there  is  a  double  row,  one  shorter,  the  other 
longer,  50-1)0  in  all,  and  the  extremities  are  furnished  with  from 
4-t)  booklets.  The  statoblasts  float  on  the  surface  of  the  water 
and  the  armed  ones  get  entangled  in  the  weed.s. 

The  method  of  production  of  true  ova  was  first  described  by 
Allman.  They  originate  in  a  bud-like  mass  at  the  upper  side  of 
the  endocyst  and  are  fertilized  by  spermatozoa,  the  testicles  being 
an  offshoot  from  the  funiculus. 

In  the  genus  Plumatella  I  have  determined  three  Canadian 
species,  (iirtlmsK,  vitira,  and  (li(/'iisii.  The  members  of  tiiis 
genus  have  dendritic,  plant-like  cocna'cia,  which  are  tirmly  at- 
tached to  the  surface  of  submerged  twigs,  stones  and  water- 
plants.  The  coonoccium  is  composed  of  little  hollow  branched 
tubules,  divided  into  cells,  from  the  apex  of  which  the  little  polyp 


protrudes,  wl 
])arcnt    polyz 
the  greater 
specimeti  of 
extent.      Tlu 
secreted  is  th 
last  dark    bn 
and  is  contini 
The  specie 
Canada  in  th 
merged   logs 
lily 

The  Crista 

have  a  loconu 

C.  Idfc  and  C 

conforms  to  t 

and  number  o 

forms.      I  ha 

gatherings,  bi: 

lakes  near  the 

County  of  Mil 

water's  edge,  i 

numerous  spec 

length  and  ont 

slow,  in  those  \ 

inch  in  the  24 

tinatella  in  pos 

six  points. 


NOTK. 1     llJlV 

tinijnislied  autli 
and  Magazine  ( 
supposed  Pterol 
eomnmnieation 
University,  in  w 
a  sunken  boat  ii 
(It'S('rij)tion  •' tin: 
liguro  and  t'ornii 
species,  are  born 
tlie  biise,'  tlio  ar 
At  the  date  of  P 
Ills  Natnral  Hist 


protrudes,  while  Mt  the  othor  end  it  is  in  communicatioi.  witl,  the 
jK.ront  polyzoon.  Ti.e  branches  are  .irencrally  Mttaeiied  alon.- 
the  greater  part  of  their  length,  though  souietinie.s,  as  i„  thi"s 
spec.Uien  oi'  P.  ar,f/,.s.,  they  ar.  Cv,.  in  nearly  the  whole 
extent.  The  color  is  owing  to  thr  .e.nev.-t,  wliieh  when  tirst 
secreted  is  thin  a.,d  j  .ilv  like  hnr  ,  h.vo,,,..  consistent   and  at 


last  dark   brown,      T 


II'   endoe\>t    lies    imiiM'i 


liately  within  this 


and  is  continuous  thnui-hout  t\u-  sy.;,,,,  of  hranche.s. 

The  species  of  this  o,,n,s  :,re  uide,y  ,ii.(,ibuted  throughout 
Canada  m  the  quiet  ponds  and  n,  nsi,.,,  aitached  to  twi..s'  sub- 
merged logs  and  the  under  surface  of  the  leaves  of  the  water- 
lily 

The  Cristatellidiu,  the  most  highly  or-anized  of  the  F^)lyzo:, 
have  a  locomotive  ca^na^eiun..      There  are  two  An.erie:,,,  species 
C.  Idac  and  0.  ophidioidea.      The  one  which  I  have  studied  hero 
conforms  to  the  latter,  as  described  by  Hyatt,  in  both  statoblasts 
and  number  of  tentacles.     It  i.s  not  nearly  so  common  as  the  other 
forms,      I  have  on  ."several  occasions  met  with  the  statoblasts  in 
gatherings,  but  have  never  found  the  polyp  except  in    the  small 
lakes  near  the  .summer  residence  of  Mr,  G,  W.  Stephens,   in  the 
County  of  M.Kskinonge.  Quebec.     In    Li.c   Rouge,  the  rocks  at 
water's  edge,  at  about  the  deptii  of  from  one  to  two  feet  presented 
numerous  sp<.cimens  about  an  inch   .and   a  h.alf  to  two  "inches  in 
length  and  one-third  of  an  inch  in  breadth.      The  movement  wa.s 
?low,  in  those  which  I  observed  in  a  small  basin,  not  more  than  an 
inch  m  the  24  hours.     The  statoblasts  differ  from  those  of   Fec- 
tinatell.a  in  po.ssessing  a  double  row  of  hooklets  with  from  two  to 
six  points. 


NoTK,_J  l.ave  received  iVoni  the  Rev.  Thomas  Hinrks,  tlie  dis- 
t.nj^nushe.l  authority  on  British  Poly/.oa.  a,  reprint  tVnni  the  Annals 
and  .Magaxine  of  Natural  History  for  Man  h,  1880,  entitled  .'On  i 
supposed  Ptcrobranehiate  Poly/.oon  from  Canada."  It  is  based  on  v 
..ommnnication  from  his  father,  the  late  Professor  Ilineks.  of  Toronto 
University,  i„  ,vhirh  a  short  aeeount  is  j^iven  of  a  ,.olvxoon  foun.l  on 
a  sunken  boat  in  the  Humher  river,  near  Toronto.  A.vonUug  to  the 
des.T,,,tion  .'the  tentacles,  instead  of  being  disposed  in  a  horse-shoe 
ligure  and  terming  a  rontinuous  series,  as  in  the  <.rdinarv  fresh-water 
speeie.s,  are  born.,  on  two  distinct  erect  lobes,  which  are  separate.l  at 
the  base,  '  the  arrang..ment  met  with  in  the  Ptcrobranehiate  Polyzooa 
At  tl...  date  of  Professor  Ilineks'  letter,  Der,  1808,  I  wa.s  u  student  in 
Ins  Natural  History  .lasses,  an<l  during  the  autumn  of  08  had  often 


«    '    J: 


•J 


8 

taken  him  specimens  of  various  sorts,  nnd  among  them  a  mass  of  Pec- 
tinntilla,  wliicli  I  had  found  in  an  old  submcrfjed  barfre  noar  tlie 
month  of  the  llinnber.  I  rcniombur  tlic  fact  very  distinctly,  as  it  was 
the  first  specimen  of  Poctinatclla  which  I  had  found  near  Toronto, 
iind  Professor  HincKs  took  a  great  interest  in  it.  as  lie  had  not  mot 
with  any  fresh-water  Poly/.oa  in  Canadfi.  CJoiild  this  have  been  the 
specimen  '.'  It  is  a  curious  coincidence,  to  say  the  least,  and  perhaps 
in  a  look  through  the  JIuseum  of  the  University  the  specimen  might 
he  found,  and  the  statohlasts  would  be  suftici(mt  to  decide  the  ques- 
tion. Professor  ITineks  gives  a  sketch  of  the  lophophore  and  it  is  hard 
to  think  that  he  could  have  been  mistaken  as  he  was  an  unusually 
skilful  observer.  The  submerged  barge  was  for  many  years  a  favorite 
collecting  ground,  and  in  some  seasons  Pectinatella  was  very  abun- 
dant in  the  quiet  water  inside  of  it. 


r*oKi 


Professor  of 


;1|    t 


PJU 


Liv 


AN    INVESTIGATION 


INTO   THE 


PARASITES 


I.N    THE 


Pork    Supply   of   Montreal 


m 


\\ 


ill 


i 


It  •: 


WILLIAM    OSLEB,   M  D,    M.R.C.P,,    Lond., 

Professor  of  the  Institutes  of  Medicine,  McGill  University ;  Lecturer 
Helminthology,  Montreal  Veterinary  College. 


on 


AMD 


A.    W.    CLEMENT    (LAWKENCE,  MASS.), 
Student  Montreal  Veterinary  College. 


I  ^ 


1 

i'  ■ 

0    ■ 

1 

( 


'  11 


MONTREAL : 

PJUNTKD   15Y  THE   GAZETTE  PRINTINO  COMPANY. 

1883. 


iM^ 


ItEPRINTE 


i  li 


1 


I 


PARASI'J 


In  the  in 

portance  th 

supervision. 

In  this  cour 

ing  thereto 

ciples.     Sp( 

examination 

killed  at  t\ 

shown  by  th 

It  is  to  b( 

there  are  soi 

will  be  of  r 

unfit  for  foo( 

a  careful  ins 

but  slightly  ■ 

its  flesh  in  i 

may,  on  sup^ 


*  Jiead  be/ore  th 


REPJUNTED  rjlOM  THE 


•CANADA   MEDICAL  .t   SURGICAL  JOURX  \L 
JANUARY,   1883. 


AN     INVESTIGATION 


i'  .1 


INTO    THS 


PARASITES  IN  THE  PORK  SUPPLY  OF  MONTREAL. 


In  the  mterests  of  public  health,  it  is  a  matter  of  great  im- 
portance that  the  food  supply  of  cities  should  undergo  strict 
supervision,  with  a  view  of  excluding  possible  sources  of  disease. 
In  this  country,  the  department  of  the  civic  governments  relat- 
ins   thereto   o.annnt-  ha  c^:a  i,   l.  -i     .    , 


xu„    i.  ,  '"'*"'  j^uvenimencs  reiat- 

thereto  cannot  be  said  to  be  conducted  on  model  prin- 
ciples.    Speaking  of  Montreal,  meat  inspection  consists  in  the 
examination  of  the  carcasses  of  all  anim'ls  exposed  fo^  sale  o 
kil  ed  at    he  abattoir,  and  its  superficial  character  is  clear  y 
shown  by  the  results  of  this  investigation  ^ 

It  is  to  be  remarked  that,  in  the  matter  of  meat  inspection, 
th  re  are  some  affections  in  which  an  ante-mortem  examination 

rl  f  f  Tl  '""'"'"'  '"^  '"  ^"^^^^  '''y  be  condemned  as 
unfit  f  r  food,  the  meat  of  which,  when  dressed,  might  pass  even 
a  -refuhnspector  There  are  other  affections  ;hich,  interferLg 
but  shgh  ly  with  the  general  healthfulness  of  an  animal,  rendef 
i^s  flesh  m  the  highest  degree  unfit  for  food,  even  though 
may,  on  superficial  inspection,  look  healthy  enough. 


(i  II 


m 


If  i" 


The  flesh  of  swine  forms  one  of  the  great  staple  articles  of 
food  in  the  community,  and,  fresh  or  salted,  constitutes  a  very 
considerable  proportion  of  all  meat  eaten.  The  hog  is  omnivorous, 
a  dirty  feeder,  refusing  nothing,  and,  regarded  from  this  stand- 
point, we  do  not  wonder  that  in  the  sanitary  enactments  of 
Moses  it  was  excluded,  though  cloven-footed,  in  the  list  of  animals 
permitted  to  be  eaten.  Vile  feeder  though  it  be,  the  hog  has  the 
power  of  converting,  in  the  laboratory  of  its  tissue?,  even  refuse 
and  garbage  into  a  flesh  most  wholesome  as  well  as  toothsome. 
Who  does  not  remember  Lamb's  charming  "  Dissertation  on 
Roast  Pig,"  and  though  he  speaks  of  the  suckling,  most  of  U3 
can  agree  with  him  when  he  says,  "'  Pig — let  me  speak  his 
praise — is  no  less  provocative  ot  the  appetite  than  he  is  satisfac- 
tory to  the  criticalness  of  the  censorious  palate.  The  strong  man 
may  liatten  on  him,  and  the  weakling  refuseth  not  his  mild  juices," 

The  hog  ''■  not  subject  to  many  diseases  which  interfere 
with  the  market  value  of  the  flesh.     Pig-typhoid  or  hog  cholera 
is  the  only  extensive  epizootic  disease  among  them  in  this  coun- 
try, and  by  interfering  with  nutrition  and  producing  emaciation 
renders  the  flesh  unsuitable  for  food.  The  injurious  effects  which 
follow  the  eatin"  of  the  flesh  of  diseased  animals  are  really  not 
much  known.     The  juices  of  the  stomach  are  so  powerfully 
antiseptic  and  corrective,  that  the  meat,  after  cooking,  is  usually 
digested  without  difficulty.     The  Highland  shepherds  are  stated 
to  eat,  without  ill  effects,  the  flesh  of  animals  which  have  died  of 
anthrax.     In  the  case  of  pork,  it  is  not  so  much  the  fresh  or  salted 
meat  which  has  been  known  to  produce  sickness  as  when  it  is  made 
into  sausages  and  brawn  (head  cheese).     Many  cases  of  serious 
illness  have  been  excited  by  eating  these  articles.  This  is  not  sur- 
prising to  anyone  who  has  watched  their  manufacture,  particularly 
sausages.     In  many  establishments  the  odds  and  ends  go  for  the 
mince  meat,  and,  too  often,  bits  of  old  meat  which  is  just  begin- 
ning to  turn.     The  experience  is  only  too  common  of  tasting  in 
a  mouthful  of  sausage  the  disagreeable  flavor  of  a  morsel  which 
is  high,  i.e.,  is  in  the  initial  stages  of  putrefaction.     The  septic 
matter,  if  abundant,  or,  perhaps,  if  produced  by  bacteria  of  a 
special  variety,  may  excite  severe  intestinal  symptoms,  and  even 


cause  dea 
a  local  ep 
Jn  reia 
small  mat 
flesh,  and 
fatal  affec 
tive  meat 
annually  p 
the  preval 
thousand 
stated.  ( 
important 
ticercus  o 
these  in  oi 

"Anextre: 
and  sexuallj 
while  the  pt 
of  an  inch  ; 
rather  thick( 
finely  poiute 
terior  e.Ktren 
.  .  .  female  si 
suring  TiV.T  t 

— COBBOLI). 

Since  Z 

a  severe  m 

to  it,  not  e; 

of  epidemic 

out  of  all  p 

enough,  for 

boring  and 

the  tragic  f 

held  an  ant 

trichinae,  w! 

fibres,  and  { 

inspection,  I 

they  are  ur 

for  years  in 


^  '^^ 


5 

cause  death.     In  Whiteehurch,  En^rland,  there  has  recently  been 
a  local  epidemic  produced  b_y  eating  brawn. 

In  relation  to  public  health,  the  diseases  of  the  hog  are  of 
small  matter  in  comparison  with  tlio  parasites  which  in^fest  its 
flesh,  and  which,  eaten  by  man,  may  produce  serious  or  even 
fatal  affections.  It  is  as  a  protection  against  these  that  an  effec- 
tive meat  inspector  may  do  good  service  in  the  community,  and 
annually  prevent  many  cases  of  illness.  To  obtain  evidence  of 
the  prevalence  of  parasites  in  the  pork  supply  of  this  city,  one 
thousand  animals  have  been  examined,  with  the  results  here 
stated.  Of  the  parasites  which  infest  the  hog,  only  three  are  of 
importance  in  this  connection— the  Trichina  spiralis,  the  6>- 
ticerous  cellulosce,  and  the  Echinococcns.  We  shall  consider 
these  in  order. 

TRICHINA  Sl'IRALIS. 
"Anextremely  minute  nematoid  heluuiuh,  the  male  in  its  fully  developed 
and  sexually  matured  condition  measuiini;  only  one-eighteenth  of  an  inch, 
while  the  perfectly  developed  female  roaches  a  length  of  about  one-eighth 
of  an  inch  ;  body  rounded  and  filiform,  usually  slightly  bent  on  itself, 
rather  thicker  behind  than  in  front,  especially  in  the  males  ;  head  narrow' 
finely  pointed,  unarmed,  with  a  simple,  central,  minute  oval  aperture;  pos- 
terior  extremity  of  the  male  furnished  with  a  bilobed  caudal  ajipendage, 
.  .  .female  shorter  than  the  male,  bluntly  rounded  posteriorly,  eggs  mea- 
suring -r;,J,-,T  of  an  inch  from  poli^  to  pole ;  mode  of  reproduction  viviparous." 

— CoBIiOIil). 

Since  Zenker,  in  1860,  discovered  that  this  worm  produces 

a  severe  malady  in  man,  a  degree  of  interest  has  been  attached 

to  it,  not  exceeded  by  any  known  human  entozoon.    The  record 

of  epidemics  of  it  sends  a  thrill  of  horror  through  a  community 

out  of  all  proportion  to  the  gravity  of  the  disease ;  and  naturally 

enough,  for  the  very  thought  of  myriads  of  these  little  worms 

boring  and  eating  the  flesh  is  particularly  repulsive,  recalling 

the  tragic  fate  of  Herod,  on  whom  the  worms  are  stated  to  have 

held  an  ante-mortem  feast.   The  hog  is  the  natural  bearer  of  the 

trichinae,  which  exist  in  the  flesh,  coiled  up  between  the  muscle 

fibres,  and  are  so  minute  that  they  cannot  be  seen  on  ordinary 

inspection,  but  require  the  use  of  the  microscope.     In  this  state 

they  are  undeveloped  or  immature  sexually,  and  may  remain 

for  years  in  the  muscles  of  the  animal  without  undergoing  de- 


i-i 


I' 


;  M. 


'Li 


i^Jji 


e 


ytenorative  oliaimos. 


-il     1 


Pork  containing  them  and  eaten  raw,  in 
any  form,  or  partially  cooke  1,  produces  disease  in  the  following 
way :  the  little  worms  escape  in  digestion,  pass  into  the  sma'l 
intestines,  grow  rapidly,  'oocome  sexually  mature,  and  assume 
the  form  of  intestinal  trichiiue.  The  females  are  impreg- 
nated, and  the  ova  devc!'>p  into  minute  embryos,  which  are  born 
alive  and  free.  This  prucess  occupies  two  or  three  days,  and  is 
usually  accompanied  with  some  intestinal  irritation.  The  number 
of  embryos  will  vary  with  the  number  of  worms  ingested  and  which 
reach  maturity.  They  immediately  burrow  through  the  walla 
of  the  intestine,  reach  the  connective  tissues  of  the  abdomen, 
and  penetrate  the  muscles  in  all  direction,  and  when  numerous 
reach  even  those  most  distant.  In  this  migration  they  produce 
irritation,  fever,  and  constitutional  disturbance  proportionate 
to  their  number,  and  the  severity  of  the  symptoms  may  be  such 
that  death  may  follow,  though  the  percentagt'  of  fatal  cases  is 
small,  only  about  1.5. 

Record  of  Invextuiation. — One  thousand  hogs  were  examined, 
chiefly  at  the  Dominion  Abattoir,  during  the  past  six  or  eight 
months.  There  was  no  selection  made,  bnt  the  carcasses  were 
taken  indiscriminately,  as  they  were  found  at  the  time  of  the 
visit. 

Method. — It  has  been  satisfactorily  shown  by  many  observers 
that  the  pillars  of  the  diaphragm  are  the  most  suitable  muscles 
for  exami"ition,  not  alone  because  portions  can  be  removed  with- 
out disfigurement  or  loss,  but  chiefly  from  the  fact  that  here,  if 
anywhere  in  the  body,  the  parasites  will  be  found, as  these  muscles 
lie  in  the  direct  route  from  the  intestines.  The  examination  was 
made  with  No.  2  Obj.  (Verick)  and  No.  1  Ocular,  magnifying 
about  60  diameters.  Small  clippings  of  the  muscle  were  made 
lengthwise,  then  placed  on  the  slide,  and  pressed  out  with  the 
top  cover  until  thin  enough  for  the  purpose.  In  only  four  out 
of  the  one  thousand  animals  were  the  parasites  present  in  the 
diaphragm,  and  we  may  take  this  as  representing  the  actual  ratio, 
though  possibly  they  may,  in  one  or  two  instances,  have  existed 
in  other  muscles  and  not  in  the  portions  examined.  As  to  the 
number  in  the  infested  bits,  in  one  case  there  were  twelve  on  one 


slide  ;  in 

regularly 

placed  on 

All  the 

Compa 

figures  sh 

Thus,  in  ] 

in  the  dirt( 

All  of  the 

one  series 

and  systei 

only  1  in 

2,800. 

Trichin 

infection  ;> 

nine  perso 

which  was 

gastro-inte 

moderate  { 

berated  by 

harpooned 

of  a  family 

infected  ha 

the  father  ; 

room,  it  is 

cysts  conta 

had  been  r( 

nected  ther 

cases  occur 

fever.     In 

four  bodies 

calcified,  an 

other  cases 

one  of  ther 

So  that  in  a 

nized  in  this 

*  Canada  SI 


slide  ;  in  the  others,  not  so  numerous.  The  worms  wore  not 
regularly  encysted  but  coiled  up  between  the  fibres.  When 
placed  on  the  warm  stage,  they  displayed  movements. 

All  the  animals  examined  were  from  Western  Canada. 

Comparison  of  local  iviih  foreign  reeor<h.~-As  the  followin'' 
figures  show,  the  record  here,  1  in  250,  is  by  no  means  high! 
Thus,  in  Boston,  Mr.  Billings  examined  over  0,000  animals,  and 
m  thedirtbrent  groups  the  ratio  ranged  from  1  in  17  to  1  in  44. 
All  of  these  animals  were  from  the  Western  States  In  Chicago" 
one  series  gave  1  in  49.8.  In  Prussia,  where  a  very  thorough 
and  systematic  pork  inspection  is  carried  out,  in  the  year  1876 
only  1  in  2,000  was  found  affected,  and  in  1877  about  1  in 
2,800. 

Trichinosis  in  Cawac^a.— Remarkably  few  cases  of  trichina 
infection  are  known  to  have  occurred  in  this  country.    In  1869 
nine  persons  were  attacked  in  Montreal  after  eating  of  fried  ham, 
which  was  ascertained  to  be  triohinous.     They  presented  severe 
gastro-intestinal  symptoms,  and  the  constitutional  disturbance  in 
moderate  grade.    None  of  them  died.    The  diagnosis  was  corro- 
borated by  the  microscopic  examination  of  a  portion  of  muscle 
harpooned  from  one  of  the  patients.*    In  1868,  three  members 
of  a  family  in  Hamilton  were  attacked  after  eating  portions  of  an 
infected  ham.     Two  of  these,  the  mother  and  daughter,  died  ; 
the  father  recovered.     At  post-mortems  and  in  the  dissecting- 
room,  it  is  not  uncommon  to  find  the  muscles  full  of  calcified 
cysts  containing  the  worms  or  their  remnants.  These  little  bodies 
had  been  recognized  for  years  before  Zenker's  discovery  con- 
nected them  with  an  antecedent  disease.  Probably  many  isolated 
cases  occur  which  are  mistaken  for  acute  rheumatism  or  typhoid 
fever.     In  between  800  and  900  autopsies  made  by  Dr.  Osier, 
four  bodies  have  been  found  trichinous,  the  cysts  in  each  instance 
calcified,  and  in  one  the  worms  were  nearly  all  dead.     In  the 
other  cases  the  parasites  were  still  living,  and  with  muscle  from 
one  of  them  the  disease  was  artificially  produced  in  a  rabbit. 
So  that  in  all  only  sixteen  cases  of  the  disease  have  been  recog- 
nized in  this  country. 

•  Canada  M-dical  Journal,  1870. 


*  ii 


ill 


'i 


Summary. — So  far  as  it  is  legitimate  to  draw  deductions  from 
the  somewhat  limited  number  of  observations,  we  may  say  that 
trichinosis  is  a  tolerably  common  affection  in  Canadian  swine, 
though  not  nearly  so  frccjuent  as  in  the  neighboring  States,  still,  it 
is  much  more  so  than  is  desirable  in  the  interests  of  public  health. 
Should  microscopic  examination  of  the  flesh  be  included  in  the 
inspection  ?  is  a  (i[ue8tion  which  at  oncc  arises.  In  answering 
this,  several  circumstances  must  be  taken  into  consideration.  In 
the  first  place,  although,  per  1,000,  a  larger  number  of  swine  are 
infested  here  than  in  Germany,  trichinosis  in  man  is  with  us  a 
very  rare  disease,  while  in  Germany  epidemics  are  of  yearly 
occurrence.  If  we  estimate  that  100,000  hogs  are  killed  annually 
for  the  local  markets,  that  would  give  at  least  three  or  four  hun- 
dred trichinous  animals,  whose  flesh  is  consumed  by  the  pork- 
eating  members  of  the  community.  Then,  about  3^  million 
pounds  of  American  pork,  representing  about  15,000  hogs,  have 
been  imported  into  this  city  during  the  past  year,  and  as  in  them 
the  percentage  of  trichinae  is  considerably  higher  than  in  Cana- 
dian animals,  the  probable  number  of  infested  carcasses  consumed 
does  not,  at  the  lowest  estimate,  fall  short  of  five  hundred.  Now, 
were  the  habits  of  the  people  vi  this  city  aimilar  to  those  of  the 
Germans,  there  can  be  no  doubt  that  trichinosis,  instead  of  being 
a  rare  affection,  would  be  extremely  common.  Fortunately,  raw 
or  only  partially  cooked  pork  is  not  often  eaten  here,  nor  are  the 
various  kinds  of  sausages,  so  dear  to  the  Teuton,  much  in  vn^'ue. 
Knackwiirste  ami  Bratwiirste,ionns  of  -ausages  which  are  very 
common,  and  which  are  eaten  either  raw  or  only  warmed,  have 
been  the  sources  of  a  large  proportion  of  the  known  cases  of 
trichinosis  in  Germany,  970  out  of  1,267.  People  here  almost 
invariably  fry  sausages,  and  smoked  meats  are  not  common,  nor 
are  they  eaten  without  preliminary  cooking.  In  short,  the  pro- 
phylaxis of  the  pot  and  oven  in  this  country  and  in  the  neighbor- 
ing States  does  more  for  tlio  public  than  the  most  stringent 
inspection,  even  as  carried  out  in  Prussia,  where  a  microscopic 
examination  is  compulsory.  If  thoroughly  cooked,  the  trichinae 
are  killed,  and  may  be  eaten  with  impunity  ;  and,  fortunately, 
there  is  a  very  widespread  idea  in  the  community  that  pork,  in 


all  forms,  s 
attributed 
enjoyed.  ! 
tity  of  tricl 
probably  ex 
causes.  Tl 
now,  under 
the  flesh  of 
require  a  sti 
such  as  our 
considering 
to  leave  the 
long  and  so 
that  all  porl 


This  para 

more  commc 

larval  or  imi 

popularly  kr 

tested  anim£ 

country  mai 

Tcenia  aolii 

from  measle_ 

the  one  is  of 

The  life       . 

worm  occupi 

of  from  12  t( 

the  body  is 

head,  and  al: 

female  gener 

and  eggs  are 

that  there  i 

number  in  ei 

The  hinder 

indeed,  may 

and  pass  awa 


\  ^^^, 


9 

all  forms,  should  be  well  cooked,  and  to  this  good  custom  may  be 
attributed  the  immunity  from  infection  which  the  public  has 
enjoyed.  Still,  it  is  by  no  means  pleasant  to  think  of  the  quan- 
tity of  trichinous  flesh  which  is  placed  on  our  markets,  and  vi^hich 
probably  exceeds  the  entire  amount  of  pork  confiscated  for  other 
causes.  The  difficulties  in  the  way  of  systematic  insi)ection  are 
now,  under  the  Abattoir  By-law,  greatly  lessened,  but  to  subject 
the  flesh  of  every  hog  killed  to  microscopic  examination  would 
require  a  staffof  trained  inspectors  and  an  increased  expenditure 
such  as  our  civic  authorities  would  not  likely  incur.  Moreover, 
considering  the  rarity  of  cases  of  infection,  it  may  be  just  as  well 
to  leave  the  matter  to  the  cooks  of  the  community,  who  have  so 
long  and  so  faithfully  protected  us,  with  this  injunction,  «  See 
that  all  pork  is  thoroughly  roasted,  fried,  or  boiled." 

CYSTICERCIIS   CELLULOSJE. 

This  parasite  of  pork  is  not  so  formidable  as  the  trichina,  but  is 
more  common  and  a  more  freqtiont  excitor  of  disease.     It  is  the 
larval  or  immature  form  of  nn^  .     the  tapeworms  of  man,  and  is 
popularly  known  as  the     uieasle  "  or  cystic  worm,  and  an  in- 
fested animal  or  its   Hesh  is  said  to  be  "  measley."     In   this 
country  man  is  infested  with  two  chief  forms  of  tapeworm,  the 
T(enia  solium  and  the  Tcenia  saginata—the  former  derived 
from  measley  jM^rk,  the  latter  from  measley  veal  or  beef;  hence 
the  one  is  often  called  the  pork  and  the  other  the  beef  tapeworm. 
The  life         ly  of  the  Tcenia  solium  is  as  follows  :— the  udult 
worm  occupies  the  small  intestine  of  man,  and  attains  .i  length 
of  from  12  to  lo  feet,  or  even  longer.     The  segments  of  which 
the  body  is  made  up  progressively  increase  in  width  from  the 
head,  and  about  the  400th  become  mature— u.,  the  male  and 
female  generative  system  which  each  possesses  becomes  active, 
and  eggs  are  formed.     In  a  fully  grown  worm  it  is  estimated 
that  there  may  be  about  200  ripe  segments  full  of  ova,  the 
number  in  each  one  reaching  probably  as  high  as  fifty  thousand. 
The  hinder  segments  of  a  tapeworm  are  constantly  shed,  or, 
indeed,  may  detach  themselves,  at  the  rate  of  3  or  4  per  diem. 


and  pass  away  in  the  faeces.     The  eggs  are  small,  round, 


roijof 


?  ;. 


i 


:  .  Jr 


il' 


!  3f  , 

1 

V  ' 


■i 


fiff 


10 

an  inch  in  diameter,  and  each  one  contains  in  its  interior  a  little 
body  known  as  the  six-hooked  embryo.  For  their  further  growth 
it  is  necessary  that  they  reach  the  interior  of  some  animal  in 
which  they  can  develop.     The  hog  is  the  most  suitable,  and 
usually  furnishes  the  means  for  the  subsequent  growth  of  the  ova, 
though  the  eggs  may  be  accidentally  ingested  by  man  and  de- 
velop within  him,  but  this  rarely  happens.     It  is  not  difficult  to 
understand  how  hogs  become  infested  ;  they  are  such  dirty 
feeders  that  nothing  is  refused,  and  even  human  excrement  is 
greedily  eaten.     In  country  places,  a  single  case  of  tapeworm 
may  serve  to  infest  many  hogs,  as  the  ripe  segments  constantly 
pass  with  the  faeces,  and  one  or  two  will  suffice  to  produce  the 
mischief.     The  eggs  in  the  stomach  of  the  pig  are  digested,  and 
the  little  six-hooked  embryos,  in  this  way  set  free,  immediately 
begin  to  bore  through  the  walls,  and,  entering  the  vessels,  are 
carried  to  all  parts  of  the  system,  lodging  particularly  in  the 
liver  and  muscles  ;  others  pass  through  the  coats  of  the  bowels 
into  the  peritoneum  and  omentum,  and  may  reach  the  muscles 
in  this  way.     In  these  various  parts  the  little  embryos  gradually 
develop  into  cysticerci  or  "  measles,"  and  an  animal  so  affected 
is  said  to  be  measled.     It  takes  about  three  months  for  this  pro- 
cess, and  when  completed,  the  cysticerci  present  the  appearance 
in  the  flesh  of  greyish-white  rounded  bodies  from  one-tenth  to 
one-sixth  of  an  inch  in  diameter,  situated  between  the  fasciculi 
of  muscles,  and  can   be   picked   out,  leaving  little   holes  or 
depressions.    When  abundant,  they  give  a  very  characteristic 
aspect  to  the  flesh,  which  is  quite  unmistakeable.     In  the  liver 
they  may  attain  a  larger  size,  and  in  the  loose  tissues  of  the 
omentum  and  peritoneum  they  are  often  found  the  size  of  a  wal- 
nut. The  cysticercus  or  measle  is  enclosed  in  an  external  sheath, 
which,  when  open,  gives  exit  to  a  cystic  or  biadder-like  body, 
which  requires  careful  dissection  to  make  out  the  structure.     It 
presents  a  head  similar  in  all  respects  to  that  of  the  adult  tape- 
worm from  which  the  egg  was  derived,  presenting  four  sucking 
disks  and  a  circlet  of  booklets.     A  narrow  neck   succeeds  the 
head,  and  beyond  this  there  is  a  bladder-like  body  called  the 
caudal  vesicle. 


If  flesh  I 

tially  cook( 

ing  the  cys 

and  passes 

by  means  c 

is  digested 

gradually  i 

tained  mati 

sands  of  e<r 

pig  that  ac( 

Local  Hi 

i.e.,  1  in  Ic 

sible  to  exa 

one  or  two 

developed. 

parts,  but  t 

has  been  ex 

the  flesh. 

In  order 
meat  produ 
issued  a  cii 
cases  under 
doctors  who 
Company's  ( 
are  treated  ; 
but  wo  shal 
number  in  tl 
are  due  to 
measley  por 
ined  it  woulc 
more  provak 
record  above 
greater  freqi 
the  beef  mea 
more  thorou^ 
less  pork  is  e 
are  usually  s 


11 

^  If  flesh  containing  these  "  measles  "  is  eaten  raw  or  only  par- 
tially cooked,  tapeworm  is  liable  to  result.  The  cyst  wall  enclos- 
ing the  cysticerci  is  digested  away,  the  bladder  worm  set  free, 
and  passes  into  the  intestine,  where  the  head  fixes  itself  firmly 
by  means  of  the  sucking  disks  and  booklets.  The  caudal  vesicle 
is  digested  away,  and  by  a  process  of  budding  the  segments  are 
gradually  formed.  In  about  two  months  the  worm  has  at- 
tained maturity,  and  sogme-'is  are  discharged  containing  thou- 
sands of  eggs,  ready  for  de  .opment  in  the  body  of  the  first 
pig  that  accidentally  ingests  the  segments. 

Local  Eecord.~Oi  1037  hogs  examined,  76  were  infested— 
I.e.,  1  m  13.6.  Only  the  livers  were  inspected,  as  it  was  impos- 
sible to  examine  the  flesh  thoroughly.  The  numbers  varied  from 
one  or  two  to  many  dozen,  and  in  most  instances  they  were  fully 
developed.  The  liver  is  more  likely  to  be  affected  than  the  other 
parts,  but  the  occurrence  in  this  organ  is  a  proof  that  the  animal 
has  been  exposed,  and  should  lead  to  a  thorough  examination  of 
the  flesh. 

In  order  to  obtain  evidence  of  the  extent  to  which  "  measled" 
meat  produces  disease— «.t>.,  tapeworm— in  the  community,  we 
issued  a  circular  to  the  city  physicians  asking  the  number  of 
cases  under  treatment.  Replies  were  returned  by  thirty-four 
doctors  who  reported  sixty-two  cases.  At  the  Smith  Worm 
Company's  office,  Bleury  Street,  about  two  new  cases  a  week 
are  treated  ;  some  of  these,  doubtless,  come  from  the  country, 
but  we  shall  [)robably  be  within  tlie  mark  if  we  estimate  the 
number  in  the  city  as  not  far  short  of  200.  How  many  of  these 
are  due  to  eating  measley  veal  or  beef,  and  how  many  to 
measley  pork,  we  cannot  say,  but  from  the  specimens  exam- 
ined it  would  seem  that  the  beef  tapeworm  (T.  mgiaata)  is  the 
more  prevalent.  Not  that  the  i)ork  measle  is  unconunon  ;  the 
record  above  given  shows  just  the  contrary.  To  explain  the 
greater  frequency  of  T.  m>/inuta,  wo  must  3up|)<)se  either  that 
the  beef  measle  occurs  in  greater  proportion,  or  else  the  pork  is 
more  thoroughly  cooked  than  the  beef  or  veal.  Then,  too,  much 
less  pork  is  eaten  fresh,  and  the  salting  and  pickling  processes 
are  usually  suificie?;'^^  to  destroy  the  measles.     A  point  of  in- 


^Ill 


^1- 


■/ 


12 


f    f  f 

I* 


terest  is  the  temperature  necessary  to  kill  them.  The  obser- 
vations of  Professor  Perronicito  prove  that  they  are  invariably 
killed  by  a  heat  of  50°C.  or  122'^F.  Indeed  they  were  swal- 
lowed with  impunity  by  iiis  students  after  exposure  to  a  tempera- 
ture of  11 8°F. 

Fortunately,  the  presence  of  a  tapeworm  does  not  give  rise  to 
such  a  formidable  affection  as  the  trichina,  but  the  amount  of 
suffering  and  annoyance  caused  is  considerable,  and  not  infre- 
quently an  individual  has  to  entertain  the  troublesome  host  for 
months  or  years,  so  difficult  is  it  in  some  cases  to  dislodge  the 
worm. 

A  thoroughly  eificient  inspection  would  diminish  greatly  the 
number  of  persons  annually  infected.  Of  course  a  hog  might 
contain  only  a  few  "  measles  "  deep-seated  in  the  muscles,  and 
these  could  readily  be  overlooked — indeed  would  be  even  on  the 
most  careful  examination. 

ECHINOCOCCUS. 

The  presence  of  this  parasite  in  the  flesh  of  pork  has  not  the 
direct  and  close  relationship  to  our  individual  welfare  as  the 
trichina  or  cysticercus,  inasmuch  as  it  represents  a  larval  form 
of  a  tapeworm  which  infesis  the  dog  and  wolf — never  man.  The 
adult  worm  is  very  small,  not  more  than  a  quarter  of  an  inch  in 
length,  with  only  four  segments,  the  anterior  of  which  forms  the 
head,  while  the  hinder  one  is  mature  and  contains  the  ova,  which 
are  passed  in  the  fajces  of  tho  dog,  and  if  swallowed  by  an  animal 
may  develop  in  its  organs  or  tissues  into  the  structures  variously 
known  as  echinococci,  hydatids,  or  acephalocysts.  A  single  egg 
of  an  ordinary  tapeworm,  when  placed  in  suitable  circumstances, 
develops  into  a  single  larva  or  measle  (^cysticercuH'),  but  a  re- 
markable peculiarity  in  the  life  history  of  the  T.  echinococcus  is 
that  a  single  egg  develops  into  a  large  compound  and  complicated 
cyst,  which  contains  many  thousands  of  larvae — hydatids  or 
hydatid  heads,  as  they  are  called — each  of  which,  if  transferred 
to  the  intestine  of  a  dog,  might  grow  into  a  tapeworm.  Man  also 
harbors  the  echinococci,  which  may  produce  very  serious  or  fatal 
disease.  In  some  countries,  as  Iceland  and  Australia,  this  affec- 
tion is  very  prevalent,  and  many  deaths  are  annually  caused  by 


the  growth 
may  form  '. 
the  hog  by 
special  int( 
rence  of 
ensures  a  < 
of  a  commi 
which  will 
condition  a 
water. 

Result  0 
cocci  were 
ranged  in  s 
ternal  >^\ 
withii  'in 
out.  The 
the  fluid  cl 
were  the  h 

Eehinoci 
affection  ; 
occur.  In 
siderable  n 
who  probal 
from  the 
may  be  ex| 
tary  regula 
Dogs  are  i 
with  the  e 
Iceland,  wl 
human  pop 
of  the  inhal 
certainly  n 
in  numerou 
occurrence 
in  man. 

*  On  Echir 
Journal  of  Me 


^, 


13 

the  growth  of  the  hydatids  in  the  internal  organs,  in  which  they 
may  form  large  tumors.  Man  gets  infected  in  the  same  way  as 
the  hog  by  the  accidental  ingestion  of  the  ova,  and  the  point  of 
special  interest,  in  relation  to  pubUc  health,  is  that  the  occur- 
rence of  echinococci  in  the  hog— and  in  other  animals- 
ensures  a  constant  perpetuation  of  the  species  among  the  do^s 
of  a  community  and  a  conse(iuent  risk  to  the  individuals  thereof, 
which  will  be  great  in  direct  proportion  to  general  insanitary 
condition  and  the  liability  of  the  eggs  to  get  into  the  drinkin'^ 
water. 

Remit  of  Uxamination. — In  the  1,037  hogs  examine'^,  echino- 
cocci were  found  in  the  livers  of  31,  or  1  in  33.4.  The  cysts 
ranged  in  siz^  from  a  marble  to  a  walnut,  and  presented  an  ex- 
ternal '  3  investment,  formed  from  the  tissues  of  the  part, 
withii'  \iW,i  was  the  cyst  proper,  which  could  be  readily  turned 
out.  The  ectocyst  and  endocyst  were  usually  well  developed, 
the  fluid  clear,  but  in  none  of  those  c  -mined  microscopically 
were  the  hydatid  heads  fully  developed. 

Echinoeoecus  disease  in  man  is  in  this  country  a  very  rare 
affection  ;  not  more  than  eight  or  ten  cases  have  been  known  to 
occur.  In  the  United  States  it  is  also  uncommon,*  and  a  con- 
siderable number  of  the  reported  cases  have  been  in  foreii'ners, 
who  probably  brought  the  parasite  with  them.  The  immunity 
from  the  disease  which  human  beings  here  happily  enjoy 
may  be  explained  by  the  existence  on  the  whole  of  such  sani- 
tary regulations  as  reduce  to  a  minimum  the  risk  of  infection. 
Dogs  are  not  numerous,  nor  are  they  so  intimately  associated 
with  the  every-day  work  of  the  people,  as  in  countries  like 
Iceland,  where,  according  to  Krabbe,  the  ratio  of  canine  to 
human  population  is  very  large,  and  an  extraordinary  number 
of  the  inhabitants  suffer  from  the  affection.  The  adult  worm  is 
certainly  rare  in  our  dogs  ;  we  have  never  met  with  a  specimen 
in  numerous  dissections,  but  its  existence  is  fully  shown  by  the 
occurrence  of  the  larval  form  in  many  animals  and  occasionally 
in  man. 


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*  On  Echinoeoecus  Disease  in  America,  by  Wm.  Osier,  M.D.,  American 
Journal  oj  Medical  Sciences,  Oct.,  1882. 


\^k  Hi  I 


11: 


14 


CONCLUSIONS. 

1.  The  investigation  shows  that  the  hogs  slaughtered  for  our 
markets  present  parasites  in  numbers  sufficient  to  necessitate  a 
more  thorough  inspection  than  is  at  present  carried  out. 

2.  As  regards  Trichina  spiralis,  which  was  found  in  the  pro- 
portion of  1  to  250,  we  are  of  opinion  that,  considering  the  ex- 
treme rarity  of  cases  of  trichinosis,  and  tlie  difficulties  attendant 
upon  a  systematic  inspection,  a  compulsory  microscopic  exami- 
nation of  the  flesh  of  every  hog  killed  is  not  at  present  called  for. 

3  In  the  case  of  "  measles,"  the  liver  should  be  carefully 
examined,  and  if  present  in  it,  the  flesh  of  the  animal  should 
receive  the  special  attention  of  the  inspector ;  if  only  in  the  liver, 
the  entire  carcass  need  not  be  confiscated. 

4.  Echinococcus  cysts  in  the  liver  render  that  organ  unfit  for 
fc  i,  but  in  other  parts,  unless  very  numerous  and  disorganizing, 
they  may  be  cut  out,  and  the  carcass  remain  marketable. 

5.  The  public  should  be  made  aware  of  the  possible  dangers 
of  eating,  in  any  form,  raw  or  partially  cooked  meat.  The  best 
safeguard  against  parasitic  aflfections  is  not  so  much  inspection 
of  the  flesh,  unless,  indeed,  this  is  minutely  carried  out,  as  care- 
ful attention  to  culinary  details. 

6.  To  reduce  the  number  of  infested  h>gs,  greater  attention 
should  be  paid  to  their  hygienic  surroundings,  particularly  in  the 
matter  of  feeding.  The  danger  is  not  during  the  period  when 
the  animals  are  penned  and  fed  on  grain,  &c.,  but  when  they 
are  allowed  to  roam  at  large  and  feed  indiscriminately. 

Our  thanks  are  due  to  the  authorities  of  the  Montreal  and  of 
Dominion  Abattoirs  who  kindly  permitted  the  inspection. 


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REPRWrEnj.Ml()M  THE  "CANADA  MEDICAL  .«•  «lIU(U('Ar.  .roURXAL." 


CLINICAL  REMARKS  ON  A  CASE  OF  IIODGKIN'S 

DISEASE. 

( ^y■Hh  n  cut.) 

Summer  Sbssion,  :\Ini)ir.\i.  F.utitv  ^Uihu.  (.'oLi.ixiio. 

By  WM.  OSLKH,  M.D.,  F.U.C.P,  Lond. 

Professor  of  the  Institutes  <,f  Mc.licii.e  in  Mc(iill  Univmsity,  and  Physician 

to  tht!  Jlontrcal  General  irospital. 

Gentlemen.— The  patient  before  you  is  the  subject  of  a 
remarkable  disease  which  was  brought  to  the  notice  of  the  pro- 
fession in  1832,  by  the  late  Dr.  Ilodgkin  of  Guy's  Hospital. 
Although  others  had  previously  described  cases,  and  Dr.  Hodg- 
kin  had  not  himself  a  very  clear  notion  of  the  relations  of  th'e 
affection,  still,  his  paper  forms  the  starting  of  our  present  knowl- 
edge, and  the  majority  of  English  writers  have,  since  1865, 
followed  Dr.  Wilks'  suggestion  and  called  the  disease  after  his 
name.     Synonyms   of   it   are    General   Lymphadenoma   or— 
adenosis,  Pseudo-Leukaemia  (Cohnhcim),  and  Addnie  (Trous- 
seau).    The  disease  is  characterized  by  a  progressive  enlarge- 
ment of  the  lymph  glands  in  certain  regions,  and  anaemia. 
There  may  be  enlargement  of  the  spleen,  and  occasionally  there 
are  localized  growths  of  lymphoid  tissue  in  different  parts  of  the 
body.   The  colorless  blood  corpuscles  are  not  usually  increased 
The  report  of  the  case  is  as  follows  :  R—  A—,  from  near  Belle- 
ville, Ont.,  was  admitted  to  Montreal  General  Hospital  June  6th 
suffermg  with  enlarged  glands.     Patient  is  34  years  of  age  ;' 
married  ;  no  children.   No  record  of  any  scrofulous  or  tubercu- 
lous affections  in  his  family.     Had  jaundice  four  years  a<ro  • 
ague  two  years    ago ;    u    hing  special   about   these   attacks! 
Otherwise  has  been  a  '     " 


quite  healthy  until  present  illness  set 


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year  and  a  halt  ago  one  of  the  glands  of  the  neck  bega 


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to  swell  and  rapidly  increased  in  size  ;  three  months  later 
another  one  on  same  side  of  neck  beyan  to  enlarge,  and  still 
later  others  beoamo  involved.  Axillary  glands  and  those  of 
groin  became  affected  six  months  later  than  the  cervical, 
but  not  to  the  same  extent.  At  times  ho  has  had  episiaxis  and 
blood-spitting,  and  he  has  lately  had  a  troublesome  cough. 

On  inspection,  patient  is  ncen  to  be  a  fairly  well  developed 
man,  dark  hair  and  eyes,  not  anaemic  or  cachectic  looking.  The 
skin  is  unusually  dark,  particularly  on  the  back  of  the  hinds,  is 
rough  and  covered  with  a  pruiiginous  rash.  The  left  arm  and 
forearm  are  swollen,  hand  not  ocdematous.  He  presents  a  re- 
markable appearance  from  the  enormous  development  of  the 
cervical  and  axillary  groups  of  lymph  glands.  From  in  front, 
the  neck  on  the  left  side  seems  almost  obliterated  by  a  largo 
mass  which  projects  over  the  clavicle  and  towards  the  shoulder, 
and  extends  from  behind  the  ear  to  the  second  interspace  on 
the  chest.  On  one  spot  there  is  a  slough,  and  about  it  the 
tissues  are  reddened  and  inflamed.  On  the  right  side  the  cer- 
vical glands  are  not  so  much  enlarged  ;  the  axillary  groups 
form  large  bunches  which  project  nearly  to  the  nipples.  Two 
isolated  glands  on  the  chest  above  the  left  nipple  are  consider- 
able enlarged.  The  veins  are  not  distended,  but  there  is  a  good 
deal  of  subcutaneous  infiltration  over  the  sternum.  Posteriorly, 
the  breadth  of  the  neck  is  very  great  on  the  left  side  from  the 
enlargement  of  the  deep  glands.  The  individual  glands  in  the 
axillae  and  right  cervical  regions  can  bo  felt ;  but  in  the  largo 
mass  in  the  left  side  they  have  more  or  less  fused  together, 
and  in  spots  have  involved  the  skin.  To  the  touch  they  are 
soft,  elastic  and  painless.  The  inguinal  glands  are  moderately 
enlarged.  The  abdomen  is  full ;  veins  not  distended.  Cardiac 
area  of  dulness  a  little  increased ;  basic  systolic  murmur ; 
nothing  special  in  right  lung ;  at  apex  of  left,  breathing  is  weak, 
but  it  is  difficult  to  examine  on  account  of  the  swellings  in  the 
vicinity.      No  difference  in  the  respiratory  sound  at  the  bases. 

Examination  of  throat  and  tonsils  shows  nothing  special.  No 
difficulty  in  swallowing;  voice  not  specially  altered,  but  he 
thinks  he  is  a  little  hoarse.   No  history  of  any  special  pain  about 


*> 


6 

bowels.    Eowol8  rather  costive.     Urine  is  slightly  high-colored, 

r  '  I'iTo^'  ?''''^'  ^^"^  '  "°  ^'^•"'"^"-  ^'^'-'  '-^O  ;  tempera- 
ture, lUlb.  Liver  and  spleen  normal.  Opthalraoscopic  exami- 
tion  of  eyes  negative.  No  hemorrhages  ;  discs  clear  On 
withdrawmg  a  drop  of  blood,  it  is  seen  to  be  of  a  fairly  good 
color,  not  watery;  on  examination  the  individual  cells  are  seen 
to  be  a  httle  pale  ;  colorless  corpuscles  relatively  increased  • 
many  smaller  than  usual;  fibrin  filaments  very  distinctly  seen' 
Ked  cells  regular  in  size.  Ilaemocytomoter  shows  about  d 
million  red  cells  to  the  cubic  millimetre  ;  a  proportion  of  1  white 
to  1;)0  red  corpuscles. 

The  patient  will  now  strip  that  you  may  sec  the  extent  of  the 
glandular  swellings ;  rarely  will  you  sco  them  more  pronounced, 
-brom  behind  the  appearance  is  even  more  strikin.r.     Fortu- 
nately for  him  the  large  bunches  on  the  left  side  Imve  grown 
outwards  and  have  not  seriously  involved  the  veins  and  there  is 
no  pressure  on  the  trachea.     The  only  interference  with  the 
circulation  is  by  the  growths  in  the  loft  axilla.     In  this  disease 
much  depends  on  the  group  of  glands  involved.  This  patient  tells 
us  that  he  has  had  little  or  no  pain  and  has  only  the  inconveni- 
ence of  these  large  tumors  which  impede  the  movements  of  head 
and  arms.     Very  much  less  swelling  of  the  internal  glands  may 
produce  intolerable  anguish  from  pressure  on  the  nerves      I 
remember  well  the  first  case  of  the  kind  I  saw.     A  large  stout 
man,  whose  only  symptoms  were  terrible  pains  ^n  the  back  and 
legs  and  oedema  of  the  feet.     The  retroperitoneal  and  pelvic 
glands  alone  were  affected  and  pressure  on  the  nerves  produced 
the   severe   pains.     When  in   the  mediastinum  the  enlarged 
glands  may  compress  the  trachea  or  bronchi  or  the  great  vessels 
and  bring  about  a  most  complicated  series  of  symptoms.     The 
case  in  No.  11  which  interested  us  so  much  a  few  weeks  ago— 
too  much,  in  fact,  as  he  got  frightened  and  left  the  Hospital- 
was  one  of  this  sort.     Extensive  pleural  effusion  on  the  left  side 
group  of  enlarged  glands  above  left  clavicle  and  a  large  bunch 
of  them  in  the  abdomen.     I  have  no  doubt  of  the  nature  of  the 
case,  but  the  pleurisy  was  the  most  prominent  feature,  probablv 
dependent  on  the  pressure  of  mediastinal  glands.     I  pass  around 


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the  photographs  of  a  case'  in  which  the  mediastinal  ^^lands  were 
chiefly  involve^!.  Notice  the  ^reat  prouunenco  of  the  sternum. 
You  notice  that  the  patient  before  yon  docs  not  look  anicmic,  much 
loss  cachectic.  ITo  has  been  a  robust,  healthy  fellow,  and  the  calls 
upon  his  reserve  fund,  by  the  growth  of  these  masses,  have  been 
so  far  well  mot,  and  though  he  has  lost  flesh,  liis  nutrition  is  still 
fairly  good.  The  blood  count  would  seem  to  tell  us  this  for  the 
percentage  of  red  corpuscles  is  not  far  off  the  nonual,  but  there 
is  a  relative  increase  in  the  colorless  cells  and  the  density  and 
size  of  the  fibrin  network  which  separates  out  Ix-tween  the  rolls 
of  red  corpuscles  indicate  disturbance  in  haematusis. 

The  pigmentation  of  the  skin  is  here  doubtless  due  to  involve- 
ment of  the  branches  of  the  solar  plexus  in  glandular  tumors, 
though  we  cannot  feel  any  through  the  thick  abdominal  walls.  I 
have  read  reports  of  two  or  three  instances  of  this  bronzing  in 
Hodgkin's  disease.  The  patient  is  quite  positive  about  the  deep- 
ening of  the  color  and  we  can  scarcely  attribute  it  to  the  prurigo 
caused  by  the  papular  rash  which  is  on  the  trunk.  Another 
point  in  this  man's  case  is  tlie  pyrexia.  As  you  see  by  this 
chart  he  has  irregular  fever,  at  times  reaching  as  high  as  102°  F. 
In  the  majority  of  instances  the  temperature  is  raised  and  it  may 
be  a  continuous  pyrexia  not  as  in  this  patient,  remittent. 

We  know  nothing  as  yet  of  the  causation  of  the  disease.  So 
far  as  we  can  ascertain  this  man  comes  of  healthy  stock,  and 
his  personal  history  gives  no  clue  to  any  morbid  influence. 
Now  that  he  has  left  the  room  w<  ;\'  discuss  freely  some  other 
questions.  The  lymphatic  tumc  ■  are  due  to  an  enormous 
increase  in  the  cellular  elements  oi  the  glands — a  progressive 
hyperplasia.  The  consistence  will  depend  on  the  amount  of 
gland  stroma;  when  abundant,  the  tumours  are  firm,  when 
scanty,  as  in  these,  they  are  soft.  You  saw  the  day  before 
yesterday  a  beautiful  example  of  lymphoid  growth,  and  as  some 
of  you  were  not  at  the  autopsy,  I  will  demonstrate  the  specimens 
again.  I  have  here  the  right  lung,  bronchi  and  trachea,  and  you 
see  these  large  tumours  about  the  latter ;  there  is  general  enlarge- 

•C'ases  of  Hodgkin's  Disuase.    (Jan.  Med.  <s  Buro.  Jouk.,  Feb,,  1881. 


mcnt  of  tho  hronchml  glands,  an.l  hero  nt  the  root  the  tissue  of 
the  nght  lung  ,s  .nva.led.    .Section  of  one  of  these  glan.k  shows 

a  soft  whUe  mate nal  which,  under  the  microscope,  is  seen  to  consist 
of  onhnary  lymphoid  cells,  with  but  little  stroma.  In  this  case 
there  was  a  secondary  growth  on  the  membranes  of  the  cord, 
and  a  small  one  n.  the  tail  of  the  pancreas.  Now  what  is  the  differ- 
ence  bet.^en  these  growths  and  the  tumors  you  have  just  seen  i. 
T         ;  """"-'^  '-.  lOiosL.mcally,  or  microscopically 

and  yet  there  .s  a  difference.     I  cod  you  that  the  bronchial' 
grow  hs  was  primary  lympo  sa. oma  ;  il  is  distinguished  from  the 
lymphoid  growths  of  Ilodgkin':  .).i.ea.  and  leukaemia  by  a  more 
rapid  deyclopn.ent,  a  greater  to:,  .ncy  to  invade  contiguous  struc- 
tures and  when  .t  generalizes,  /...,  from  secondary  tumors,  they 
may  be  m  any  and  every  organ  and  not  confined,  as  in  leuka^mic 
and  pseudo-lcuka^mic  growths  to  one  or  more  organs.  In  this  case, 
the  secondary  tumors  were  in  the  spinal  membranes  and  pan- 
creas    barcoma  of  the  lymph  glands  is  apt  to  early  penetrate  the 
capsule  of  the  glands  and  invade  neighboring  parts.     You  see 
this  m  the  lung  here  which  has  been  involved.     I  have  a  speci- 
men 0  sarcoma  of  the  tracheal  and  bronchial  glands  which  crept 
up  and  uivaded  the  thyroid.  ^ 

With  lymphatic  leukaemia,  Ilodgkin's  disease  has  many  simi- 
anties,  so  much  so  that  the  mere  absence  of  one  feature,  vh 
hemcrease  of  colorless  blood  corpuscles,  seems  scarcely  enough 
to  just,  y  their  separation.     And  further  there  have  been  cases 
m  which  the  leucocytosis,  as  exists,  for  example,  in  R-  A— 
has  increased  to  a  positive  leukemia  an.l  that  within  a  verj? 
shor  time.     Ihe  prognosis  is  as  bad  as  can  be.     The  enlarge- 
ment IS  progressive,  and  though  in  the  instance  before  us  the 
groups  involved  have  not  as  yet  seriously  interfered,  either  by 
pressure  or  otherwise,  tho  gradual  impairment  of  nutrition  and 
he  dram  upon  the  system,  by  the  suppuration  which  is  likely 
0  follow  m  the  large  mass,  will  induce  asthenia,  if  pressurl 
effects  do  not  supervene  and  bring  death  more  rapidly 

With  such  a  prognosis  you  may  judge  of  the  value  of  treat- 
ment m  these  cases.  An  import.ant  point  is,  should  the  glands 
be  excised.^    If  m  a  localized  group,  as  on  one  side  of  the 


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neck,  and  there  is  no  constitutional  disturbances — yes  ;  but  if 
several  localities  are  affected  and  there  is  constitutional  affec- 
tion  no ;   the  results  are  decidedly  against  it.     In  addition  to 

iron,  general  tonics  and  good  diet,  I  give  arsenic  in  increasing 
doses,  begining  with  two  or  three  drops  throe  times  a  day,  and 
increasing  gradually,  if  the  patient  bears  it,  to  twenty  or  thirty 
drops  daily.  Under  its  use  I  saw  the  glands  on  one  side  of 
the  neck  get  decidedly  smaller,  and  I  have  under  this  treat- 
ment at  present  a  lady  whoso  general  condition  has  much  im- 
proved, and  the  gland  swelling  considerably  diminished.  Phos- 
phorus has  been  found  beneficial  by  some  observers. 


W.  I      ? 


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PKIiATAXlCTABKSDOKSALIS. 


,1  ;•■ 


./  Clhiical  Lcclure  delivered  during  tlie  summer  session 
of  the  McGUl  Medical  Faculty. 


;r 


BY 

WILLIAM  OSLER,  M.D..  F.R.C.P.  Lond 

.■KOPHSSOR  OF  THK  .NST.TUTHS  OP  MUOicnb)  MCCUU.  COLLHOE,  MONTkLi.. 


FROM 

THE  MEDICAL  NEWS, 
August  25,  1883. 


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DOKNAN,  I'lilNTUR. 


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I'REATAXIC  TAJJES  DORSALIS. 


(iENTLKMKN:  In  locomotor  ataxia  we  may,  for  clinical 
convenience,  recognize  three  stages,  the  preataxic,  in 
which,  without  any  incoordination,  there  are  certain 
other  well-defined  and    characteristic  symptoms-    the 
ataxic,  m  which  tht  disordered  muscular  movements 
predominate;    and    a  final  pseudo-paralytic   stage,   in 
which  the  patient  is  a  helpless  cripple.     The  man  be- 
fore you  is  an  interesting  illustration  of  the  early,  or 
preataxic   stage.     You  see,   as  he  walks   around   the 
arena,  that  the  gait  is  normal,  and  you  certainly  would 
not  suppose  from  his  appearance  that  he  was  aftlicted 
with  this  disease.     From  the  fact  that  locomotor  ataxia 
may  exist  for  years  without  ataxia,  the  name  tabes 
dorsalis,  given  by  Romberg,  is  preferable,  or  posterior 
spinal  sclerosis,  which  indicates  the  location  and  nature 
of  the  lesion.     When  we  consider  that  about  fifty  per 
cent,  of  tabetic  patients  are  not  ataxic'  the  name  in 
common  use  is  misleading,  and  gives  undue  promi- 
nence to  a  symptom  which  is  often  absent. 

The  clinical  record  of  this  patient  is  as  follows: 
Samuel  S.,  of  Sherbrooke,  Que.,  aged  43,  Canadian,  a 
cabinetmaker  by  trade,  but  for  some  years  (12)  past 
a  millwright,  came  to  the  hospital  to  be  treated  for 
failure  of  eyesight.  Nothing  special  in  the  family  his- 
tory.    Has  been  married  nineteen  years;  two  children 


_    >  Erb,  in  oighty-lour  cases,  nienli,)iis  that  fortv-tliree  'v  ere  in  tlie 
initial  stage  and  presented  no  ataxia. 


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living,  three  dead;  one,  a  year  old,  had  a  rash  on  the 
body   the  other  two  were  still-born.     Had  ponorrhcua; 
can  get  no  history  of  chancre.     Formerly  tooV  sp-nts 
freely  but  has  been  temperate  for  some  years.     Has 
used  tobacco  to  excess,  also  opium      In  his  occupation 
as  millwright  has  been  much  exposed  to  wet  and  cold, 
particularly  when  working  in  the  flumes,  and  on  several 
occasions  has  been  for  hours  in  ice-cold  water,     tor 
nearly  four  years  he  has  had  what  he  calls  rheumatic 
pains  in  the  legs,  at  irregular  intervals ;  sometimes  six 
months  would  elapse,  and  at  others  two  or  three  attacks 
would  occur  in  a  couple  of  weeks.     He  describes  the 
pains  as  intense,  coming  on  with  great  rapidity,  local- 
ized often  in  spots  not  more  than  an  inch  or  two  in  ex- 
tent which  are  acutely  sensitive  when  they  are  present; 
duration  brief,  two  or  three  seconds,  and  .hen  they  pass 
away  as  quick  as  they  came,  to  return  again  in  a  few 
minutes.     Sometimes  they  have  been  so  bad  that  he 
has  not  slept;  in  his  own  words.  "  they    - onld  just  give 
me  breathing  spells!  and  then  1  had  to     inch  my  teeth 
to  bear  the   next   pain."     No   tinglip,   or   pins   and 
needles.     For  about  a  year  has  noticed  that  the  eye- 
sight was  failing  ;  may  have  been  present  for  a  longer 
time  but  he  was  not  conscious  of  it. 

Fxamination  :  Patient  is  a  slight,  dark  man.  fairly 
nourished.  Cait  is  uniffected,  Muscles  moderately 
developed.  Sensation  in  legs  good;  not  retarded, 
Pupils  are  contracted,  round,  measure  3.5  mm.  They 
do  not  react  to  light  (reflex  immobility,  reflex  irido- 
plegia).  Act  during  accommodation  and  in  associated 
movements  when  eyes  move  upward  and  inward.  Dr. 
BuUer  tested  the  vision,  and  reports  ,  Ijg  with  right  eye 
and  j-o\  with  left  eye.  Considerable  limitation  of  field 
of  vision  in  upper  and  outer  parts.  Optic  nerves 
bluish-white  in  color;  margins  well  de'^t  .'d  all  the 
minute  vessels  of  the  disk  are  gone,  o   .j    .    ■  larger 


trunks  remain,  and  they,  too,  are  diminished  in  size. 
Color-perception  for  red  and  yellow  good  ;  he  thought 
the  green  was  dark-brown,  almost  black.  The  patellar 
tendon-reflex  is  absent.  Plantar,  cremasteric,  and  ab- 
dominal reflexes  are  present. 

The  eye  symptonii,  lightning  pains,  THd  absence  of 
knee-jerk,  are  the  chief  features  presented  by  this  case, 
and  together  they  are  amply  sufficient  to  establish  the 
diagnosis  of  tabes  dorsalis.  Let  us  consider  these 
symptoms  a  little  more  closely,  and,  first,  the  oc>dar 
phenomena,  which  are  among  the  earliest  and  most 
remarkable  nerve  disturbances  in  the  disease,  and  of 
great  diagnostic  importance.  When  I  place  the  pa^ 
tient  before  the  window,  shade  his  eyes  with  my  hand, 
and  then  suddenly  expose  them  to  the  bright  light,  no 
change  takes  place  in  the  diameter  of  the  pupils. 
Tested  with  a  stronger  light,  the  same  peculiarity  is 
noted  ;  the  pupils  are  immobile  and  do  not  react  to  the 
stimulus.  If  now,  after  looking  at  my  fingers  at 
eighteen  inches  he  then  directs  his  vision  into  the  dis- 
tnnce,  the  pupils  dilate  with  the  relaxation  of  accom- 
modation, and  contract  again  when  '-  'ooks  at  a  near 
object.  While  not  responding  to  tin,  dmuhis  of  light, 
they  are  active  during  accommodation.  This  reflex 
immobility  of  the  pupil,  first  described  by  Dr.  Argyl 
Robertson,  and  sometimes  called  after  him,  is  present 
in  a  large  proportion  of  cases  of  tabes.  In  84  cases  of 
Prof.  Erl)  it  was  noted  absolutely  in  59,  and  diminished 
in  1 2.  Of  these  7 1  cases,  43  were  in  the  preataxic  stage 
of  the  disease.  In  Crower's  address,  just  to  hand,  on 
eye  symptoms  in  spinal  disease,  the  light  reflex  is  stated 
to  have  been  lost  in  48  out  of  72  cases.  Usually  the 
reflex  immobility  is  associated  with  myosis,  which 
exists  in  this  man  in  a  moderate  df;gree.  The  only 
other  affection  in  which  this  sign  has  been  specially 
noted  is  progressive  paresis  of  the  insane.     Not  only  is 


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the  power  of  reflex  contrnc;'>in  of  the  i>jpils  lost,  but 
reflex  dilatation  i.ay  also  :.<.  ■•  ,.>pended.  If  you  stimu- 
late strongly  the  skin  of  a  healthy  person,  a  slov;  i  eflex 
dilatation  of  the  pupils  takes  ;)!ace,  ut  in  tae  majority 
of  cases  of  tabes  ihis  does  not  occjr.  We  could  nof 
get  this  reflex  on  stron?  galvanic  stir  relation  of  the 
skin  of  the  neck  and  shoulder  of  thi  <  n.an.  The  pre- 
;;-.e  locality  of  the  lesion  which  causes  these  early 
prpil  syiiip'o"is  is  unknown,  but  if  you  consult  the 
diagr.un  of  the  pupil  centres,  which  you  have  in  your 
pi!y5ioloj.;y  notes  of  last  winter,  you  v>.!'  see  that,  as 
Erb  says,  the  local  degeneration  causi<  g  the  loss  of 
light  reflex  must  be  somewhere  in  the  pathway  between 
the  centres  of  the  optic  and  the  third  ntrv-js. 

The  chief  complaint  of  this  patient  •-.  a  steadily 
advancing  loss  of  sight,  which  ophthaliuoscopic  ex- 
amination shows  to  be  due  to  atrophy  of  the  optic 
nerve.  Many  of  you  have  had  an  opportunity  of 
examining  the  disks  in  the  ophthalmoscope  room,  and 
studying  the  characters  of  the  sclerotic  atrophy— the 
blue-gray  color,  the  flatness  of  the  disks,  the  absence 
of  small  vessels,  and  their  sharp  distinct  outlines. 
With  no  other  spinal  affection  is  atrophy  of  the  optic 
nerves  so  frequently  associated.  It  usually  begins 
early,  before  the  second  stage  of  the  disease  is  reached, 
and  the  patient  may  be  quite  blind  by  the  time  the 
ataxia  develops,  or,  indeed,  before  there  is  a  suspicion 
of  tabes.  The  atrophy  is  progressive,  and  ultimately, 
though  it  may  be  after  the  lapse  of  months  or  even 
years,  total  blindness  results. 

Color-perception  is  often  disturbed  ;  most  frequently 
patients  lose  the  power  of  distinguishing  red  and  green, 
while  that  for  yellow  and  blue  may  be  retained.  This 
man  says  that  green  appears  to  him  dark-brown  or 
almost  black.  His  perception  of  red,  yellov, ,  or  blue  is 
good.     There  are  other  eye  symptoms,  r  ^  ^resent  in 


this  insta 

aware  of 

local  pals 

duction  c 

too,  are  ( 

common  ; 

vision,  wi 

troublesoi 

under  th( 

operation 

I   knew  a 

squint  wi 

since  becc 

tion  a  ge 

double  vii 

severe  pa 

patellar  re 

squint,  or 

possibility 

ing  for  oth 

Besides 

complaint 

at   times   i 

which   I  r 

so-called  1 

are  usuall; 

chiefly  the 

sides,  rare 

and  in  the 

months  mr 

of  their  on 

is  well  exp 

lightning. 

when  a  bac 

each  pain, 

patient  say 


iir 


this  instance,  which  may  puzzle  you  not  a  little,  if  un- 
aware of  their  connection  with  tabes.     I  refer  to  the 
local  palsies  of  the  external  eye  muscles,  and  the  pro- 
duction of  squint,   double  vision,  and  ptosis.     These, 
too,  are  often   preataxic  symptoms  and  are  quite  as 
common  as  those  which  we  have  considered.     Double 
vision,  with  or  without  positive  squint,  is  often  a  most 
troublesome  feature,  and  the  patient  may  be  for  months 
under  the   care   of   an   oculist,   or,   indeed,  have   an 
operation  performed  for  strabismus.     Some  years  ago, 
I   knew  a  gentleman  who  had  intractable  ptosis  and 
squint  without  any  other  special  symptoms.     He  has 
since  become  ataxic.    I  have  at  present  under  observa- 
tion a  gentleman  who   had   external  strabismus  and 
double  vision  for  six  or  seven  months,  and  now  has 
severe  pains,   bladder   trouble,   and    absence   of   the 
patellar  reflex.    In  adult  men,  the  occurrence  of  ptosis, 
squint,  or  double  vision,  should  suggest  to  you   the 
possibility  of  early  tabes  and  the  necessity  of  examin- 
ing for  other  signs. 

Besides  the  failure  of  vision,  the  patient  has  but  one 
complaint— the  terrible  pains  which  have  attacked  him 
at  times  during  the  past  four  years.  The  account 
which  I  read  to  you,  is  a  typical  description  of  the 
so-called  lightning  or  electric  pains  of  tabes.  They 
are  usually  mistaken  for  rheumatic  pains,  and  affect 
chiefly  the  lower  extremities,  sometimes  the  back  and 
sides,  rarely  the  arms.  They  vary  greatly  in  intensity 
and  in  the  frequency  of  their  occurrence  ;  weeks  or 
months  may  elapse  between  attacks.  The  suddenness 
of  their  onset,  the  rapid  darting  or  flashing  character, 
is  well  expressed  in  the  terms  electric,  fulgurating,  r ' 
lightning.  They  fly  about  from  place  to  place,  and 
when  a  bad  bout  comes  the  patient  may  cry  out  with 
each  pain,  and  they  may  recur  so  rapidly  that,  as  our 
patient  says,  there  are  only  breathing  spells  between 


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them  and  just  time  to  clinch  the  teeth  to  bear  the  next 
stab.     The   skin   over  the   site  of  the   pain    may   be 
intensely  sensitive— hypenesthetic.     Occasionally  the 
pains  are  dull,  heavy,  and  dragging,  not  sharp  and 
stabbing;    this,  however,  is  quite  exceptional.     Very 
few,  not  five  per  cent.,  of  ataxic  patients  escape  these 
torments.    One  other  important  symptom  is  presented 
by  this  man  ;  when  I  strike  the  patellar  tendon  of  the 
crossed  leg  with  the  rim  of  th«< stethoscope,  there  is  no 
response   in  muscular   contraction  of  the  quadriceps 
extensor,  and  the  leg  is  not  jerked  up  as  in  health. 
The  knee-jerk  or  patellar  tendon-reflex  is  absent,  and 
since  I'rof.  Westphal  called  attention  to  this  sign,  it  has 
come  to  be  regarded  as  of  great  diagnostic  value  in 
tabes.     Exceptionally,  the  knee-jerk  is  absent  in  per- 
sons in  whom  there  can  be  no  suspicion  of  posterior 
spinal  sclerosis;  but  absence  of  it  in  conjunction  with 
lightning  pains  or  any  of  the  ocular  phenomena,  may 
be  regarded  as  proof  positive  of  the  existence  of  the 
disease.      Lest  you  may  think    that   rather  a   strong 
statement,  let  me  read  you  a  paragraph  from  a  lecture 
by  Dr.  Buzzard,  whose  work  on  Disrasi-s  of  the  Ner- 
vous System   I   would   specially  commend  to   you   as 
embodying  the  rich  clinical  experience  of  an  ur.  itually 
acute  observer.     He  says,  "  It  is  of  much  importance 
to  remember  that  the  two  symptoms— on  the  subjec- 
tive side,  pains  of  the  character  described,  and,  on  the 
objective  side,  absence  of  the  patellar  tendon-reflex 
(with  a  fairly  normal  condition  of  the  quadriceps  ex- 
tensor muscle)— are  the  most  constant,   as  they  are 
probably  the  earliest  of  all.      My  belief  is  that  if  we 
meet  a  patient  who  exhibits  them  both,  we  do  not  need 
the  presence  of  any  other  in  order  to  form  a  diagnosis 
of  tabes  dorsalis."     The  patellar  tendon-reflex  is  ab- 
sent in  about  ninety-six  per  cent,  of  all  cases. 

Among  other  symptoms  which  may  be  present  in 


the   first  : 

numbness 

pronounce 

curring  wi 

Charcot,  a 

in  the  se: 

times  thei 

disease   a( 

finally   im 

mention  t( 

day  :    A   j 

gradually 

raised  by 

loss  of  sex 

The  man 

life,  had  s 

abused  his 

he  has  bee 

out  any  b 

The  testicl 

varicocele. 

presented  1 

he  does  c( 

legs.     In 

haps  initia 

not,  in  this 

Chatham,  i 

in  a  few  3 

something 

You  doul 

taken  plac 

many  facts 

Erb,  Gowei 

between  it 

ably   over 


the   first   stage   are   localized  regions  of  anicsthesia, 
numbness,  pins  and  needles,  but  more  common  with 
pronounced  ataxia;  attacks  of  obstinate  vomiting  oc- 
curring without  olivious  cause,  ihe  cn'sfs  x'tis/n't/ues  of 
Charcot,  and  vesical  and  rectal  troubles.    Disturbances 
in  the  sexual   function  are  common  in  tabes;   some- 
times there  is  at  the  onset  satyriasis,  usually  as  the 
disease   advances,  there  is  loss  of  sexual  vigor,  and 
finally  Impotence.      In   connection  with   this,   I  may 
mention  to  you  an   interesting  case  which   I   saw  to- 
day:    A   gentleman    from    near  Chatham,   Ont.,  has 
gradually  become  Impotent,  and  the  question  has  been 
raised  by  an  eminent  American  specialist  whether  the 
loss  of  sexual  power  was  not  an  early  tabetic  symptom. 
The  man  Is  powerfully  built,  accustomed  to  out-door 
life,  had  syphilis  about  fourteen  years  ago,  and  has 
abused  his  sexual  powers  to  excess.    For  three  months 
he  has  been  on  a  strict  anti-syphilitic  treatment  with- 
out any  benefit,  and  he  is  now  practically  impotent. 
The  testicles  are  soft  and  flabljy,  and  there  Is  a  large 
varicocele.      There  are  none  of  the  tabetic  symptoms 
presented  by  the  case  we  have  just  considered,  though 
he  does  complain  of  dragging  pains  at  times  in  the 
legs.      In  rare  instances,  impotence  is  an  early,  per- 
haps initial  symptom  in  tabes,  but  whether  it  is  so  or 
not,  in  this  instance,  time  alone  will  tell.     Dr.  Bray,  of 
Chatham,  under  whose  care  he  is,  will  doubtless  know 
In  a  few  years.      Possibly  the  varicocele   may  have 
something  to  do  with  his  trouble. 

You  doubtless  are  aware  that  much  discussion  has 
taken  place  lately  regarding  the  cause  of  tabes,  and 
many  facts  have  been  brought  forward  by  Fournier, 
Krb,  Cowers,  and  others  to  show  the  close  connection 
between  it  and  syphilis.  Statistics  prove  that  consider- 
ably  over   fifty   per   cent,   of    all   tabetics   have   had 


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syphilis,'  but  whether  this  is  simply  a  matter  of  asso- 
ciation, or  whether  a  Herin'*^  --usal  relationship  exists, 
is  not  yet  clear.  vj..  siioiiUt  be  esp.cialh  careful  in 
obtaining  the  history  of  a  patient  to  ascertain  if  he  has 
had  syphilis,  as  the  treatment  may  be  thereby  consid- 
erably influenced.  There  are  some  indeed  who  regard 
the  occurrence  of  tabes  as  in  itself  a  proof  of  the  ex- 
istence of  syphilis,  but  this  is  an  extreme  view  and  not 
borne  out  by  facts.  In  the  case  you  have  just  seen  we 
can  obtain  no  positive  evidence  of  infection;  true,  he 
has  been  />i  the  ivay  of  it,  having  had  gonorrhita,  and 
the  death  of  three  children,  one  with  a  general  rash,  is 
a  suspicious  circumstance,  but  he  is  an  intelligent  man, 
anxious  to  give  all  details  and  he  seems  quite  certain 
that  he  never  had  a  i,  ^re  on  his  penis  or  any  secondary 
manifestations.  It  is  astonishing  '  ow  reluctant  ome 
men  are  to  acknowledge  the  pox.  Rven  an  intelligent 
physician  will  conceal  the  act  from  his  best  friend  and 
deceive  him  grossly,  as  in  the  following  instance.  A 
few  years  ago,  after  a  medical  dinner  in  London,  the 
conversation  turned  on  this  very  subject,  tabes  and 
syphilis,  and  one  gentleman  was  \ery  positive  about 
the  invariable  .i^sociation  of  the  two.  Our  host  stated 
that  he  had  under  observation  a  medical  man,  the  sub- 
ject of  tabes,  who  of  Ted  a  s nisfactory  refutation  of 
t'>  view  as  he  had  ver  had  syphilis.  I  ascertained 
thi  name  of  the  surgeon  referred  to,  and  to  my  surprise 
found  that  it  was  a  man  with  whom  I  had  been  ac- 
quainted on  the  continent,  and  who  at  the  time  was 
undn  treatment  for  se    mdaries. 

Exposure  and  cold,  especially  with  muscular  fatigue, 
are  believed  to  be  potent   iniiuences  in  lae  etiology 


I  In  the  Vicnii; 
gical  Journal,  I)r 
ten  sypliilitk-s  in  o 


■irespoii'loiice  of  Canada  Medical  an ~i  Siir- 
s  S''  v.irt  states  tliat  Dr.  \ViNs  found  only 
and        cases  of  tabes. 


It  I  \m 

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of  tabes,  and  in  this  connection  it  is  worthy  of  note 
that  our  patient  has  been  much  exposed  to  cold  and 
wet  when  wortcin^  at  his  trade  .is  millwriKlu,  often  up 
to  his  waist  in  ice-cold  water. 

From  the  fact  that  he  has  had  lightning'  pains  for 
over  four  years  you  may  gather  that  even  the  initial 
stage  may  be  very  prolonged.     Tabes  is  perhaps  the 
most  chronic  of  all  nervous      Hections,  and  in  indi- 
vidual cases  it  is  impossible  to  predict  what  the  course 
will  be.    This  patient  may  not  become  afaxk  for  years; 
unfortunately  for  him,  the  optic  atrophy  will  almost  cer^ 
tainly    be    pro-ressive   and    lead   to   total   blindness. 
Occasionally  the  course  of  the  disease  is  very  rapi.l. 
I  had  arranged  to  show  you  another  case  to-day,  a 
pronoimced  ataxic,  with  the  characteristic  gait,  etc., 
but  he  sent  w  ord  that  he  was  too  unwell  to  come.  '  This 
man  has  had  syphilis,  has  suffered  from  cerebral  mani- 
festations, and  now  for  nearly  two  years  has  presented 
symptoms  of  tabes,  the  incoordination  being  now  so 
;,'reat  that  he  moves  about  with  very  great  difficulty. 
When  once  established,  the  disease  is,  as  a  rule,  hope- 
lessly incurable;   it  is  impossible  to  restore  sclerotic 
ner^         sue  to  the  normal  state.     The  most  we  can 
hope  iG  do  is  to  arrest  the  progress  and  alleviate  some 
of  the  more  distressing  symptoms,     Where  there  is  a 
decidedly  syphilitic  history,  as  in  the  case  I  just  referred 
to,  a  thorough  course  of  mercury  and  iodide  of  jiotash 
should  be  tried.     It  has  done  him  no  good,  but  there 
are  instances  on  record  in  which  such  a  plan  has  been 
of  material  benefit.     Of  course,  the  remedies  in  vogue 
in  the  treatment  of  the  disease  are  legion.     At  present 
great  confidence  is  placed  in  nitrate  of  silver,  ii  .juarter 
of  a  grain    doses   three   times   a   day,  continued   for 
months,  mtei  mitting   every  fifth  week  to  prevent  de- 
posit on  of  the  salt  and  staining  of  the  skin.     It  seems 
to  relieve  the  pains,  and  in  some  cases  the  incoordina- 


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1 
I  \- 


il 


1  II 


I 


la 


tion  has  disapptMied  tliirini,'  its  employment.  We  shall 
put  this  patient  on  a  |)i  'in^^'cd  i  omse  of  the  silver, 
and  order  galvanism  to  ilic  spine.  Rest  is  an  im- 
portantelenient  in  the  treatment,  hut  in  many  instances, 
as  in  this  one,  impossible  to  procure.  When  the 
electric  pains  are  severe,  friction  (massajje)  is  bene- 
ficial and  in  very  bad  spells,  hypodermic  injections  of 
morphia. 

I  have  no  belief  in  the  restitution  by  therapeutic 
means  of  a  sclerotic  tract  in  the  spinal  cord;  as  well 
iniKht  we  hope  for  restitution  of  a  group  of  sclerotic 
(cirrhotic)  liver  lobules.  Curiously  enouj^h,  even  when 
decided  amelioration  does  take  |)lace  or  a  cure  is  ap- 
parently effected,  the  lesion  in  the  posterior  columns 
may  remain  unchan^'ed.  In  one  of  the  recent  num- 
bers of  the  Anhiv Jin-  raych.,  Dr.  Schultze  reports  a 
remarkable  case  whu  h  illustrates  this.  A  patient  of 
Dr.  Krbs'  was  apparently  cured,  the  ataxia  and  pains 
disappeared ;  absence  of  ]iatellar  reflex  and  slight 
vesical  trouble  alone  remained.  Twelve  years  after 
the  appearan(  c  of  the  symptoms  of  ataxia,  and  eight 
after  their  disappearance,  he  died  of  poisoning.  At 
the  autopsy  the  posterior  sclerosis  was  well  marked  in 
the  lumbar  section  of  the  cord,  and  there  was  degenera- 
tion of  the  posterior  root-zones  in  the  dorsal  and 
cervical  regions. 

The  opinion  is  gaining  ground  that  locomotor  ataxia 
is  not  simply  posterior  spinal  sclerosis,  but  a  wide- 
spread affection  of  the  sensory  nerves  ;  and  taking  this 
view  the  various  peripheral  nerve  changes,  the  optic 
atrophy,  which  is  so  common,  the  occasional  affection 
of  the  auditory,  and  the  degeneration  of  the  cutaneous 
nerves  which  has  been  described — all  come  in  as  part 
of  the  general  affection. 


t 


/tAf 


S>. 


L.\^n 


■'■"i;  Tlllkl)  0)Rirsc-|.K  OF  TIIK  111 


OOlJ. 


-xrJl„1h;!'h;  '••/'"-■ '■'^''^'"'  -'^it'^-nn.s.Ies,  there 
art  1.    the  blood  granular  bodies  ..f  various  si/e 

limes  ab  large.      I  iiese  were  first  described  l)v  \fiv 
Schuitze,  and  they  n,ay  be  called  very  a,^  ro|natdy 
as   I  have   been    .n    the   habit  of  ,io„  g  fo'r  years' 
Schultze's   granule    masses."      I„    healthy    idn    ; 
t  >ey  are  not  abundant  as  a  rule,  though  eLntIo 

:  bound'"7n';i,'"  7""""">'  ^""^  'ondition'  th  V 
aoound.     In  all  cachectic  states  the  granule  masses 

n^\Z^\ '"^  """'^°""     '''''^">'  ^«'»^  notable  featu 

kS.nH  ']^  "^"""''^  generally;  also  in  leu- 

kc^mia  and  symptomatic  anaemia;    but  it  is  not  a 

i.^    cZ'o,  ''-^  ^''/   '"   '^^^"'''""^  an.mia  tile- 
are  scant),  oi  even  absent.     In  the  lower  animals 
tl  e  ,„asses  are  met  with  in  variable  nu.nberr  The 
blood  of  the  young  contains  them  i„  larger  pro,  o 
ion  than  ,n  adults.     The  new-born  rat,  kitten    ra| 

th  ir"  S;r%'^'^  ""^'  '"  ""''''  ^^'"^  advantage  for 
tneir  study.     So  common  are  they  in  the  blood  of 

misTa  irv^;^'^  •'"'  '  '-^  "'^'  '''  ^'  wondered  at  i 
mistakes  have  arisen  cone  erning  the  signs  of  their 

presence  in  certain  diseases.     Thus,  in  ^ThTlanlt 

a  few  years  ago,  a  gentleman  described  them  under 

e.'.S'"r^"*'  "'^-^'"^-  i"  leuaemic  blood,-' 
regarding  them  as  specific  urrharacteristic  elemen  s 
I  laye  been  told  of  a. somewhat  prominenrlondon 
physician    connected  w.th  one  of  the  special  hisp 
tals  for  chest  diseases,  who  found  them  so  co  isSnt 


1  ;■ 


I  i 


iii,ii- 


,1  '■^■•'^\ 


if 


in  the  blood  of  ])hthisical  patients  that  he  regarded 
tlicni  as  ]ieruliar  to  the  disease,  until  advised  by  a 
colleague   of  tiieir   wide   distriJMition.     The    most 
extensive  observations  upon  their  presence  in  dis- 
ease  were    made    l)y    Dr.    Reiss.'      The    common 
opinion  regarding  them  has  been  that  they  repre- 
sent degenerated  white  blood-corpuscles,  or  a  gran- 
ular detritus   resulting    from    their  decay.      1    first 
showed  that  they  were  composed  of  distinct  cor- 
puscles, and  that  the  masses  did  not  preexist  in  the 
blood,  but  were  formed  at  the  moment  of  withdrawal 
by  the  aggregation  of  the  cor|)uscles.     At  the  edges 
of  large  groups,  the  disk-like  corpuscles  can  be  dis- 
tinctly seen,  and  in  the  sulphate  of  soda  solution, 
such  as  used  for  mixing  the  blood  in  hfemocytometer 
work,  the  corpuscular  nature  of  the  masses  is  quite 
clear.     Hut  what  led  me  to  this  point  was  the  fact  of 
the  impossibility  of  supposing  that  masses  of  the  size 
of  some  of  these  could  pass  through  the  capillaries. 
Reiss  felt  the  same  difficulty,  and  suggested  that  in 
some  cases  they  might  produce  embolism.      In   the 
l)lood  of  the  new-born  rat  they  are  most  abundant, 
and  the  subcutaneous  tissue  was  employed  to  inves- 
tigate the  condition  of  the  masses  within  the  ves- 
sels.    It  was  then   found  that  they  do  not  preexist 
as  aggregations  in  the  blo'  d,  but  are  in  the  form  of 
isolated  corpuscles  floating  free  with  the  other  forms. 
By  far  the  simplest  way  of  demonstrating  the  iso- 
lated corpuscles  in  the  vessels  is  to  snip  a  small  bit 
of  the  subcutaneous  tissue  from  a  young  rat,  and 
examine  in  salt  solution. 

In  a  small  artery  or  vein,  there  will  be  seen  with 
the  red  and  white  cells  small,  pale  corpuscles  about 
one-fourth  the  size  of  the  red  ones,  often  in  extraordi- 
nary numbers  (Fig.  i).  A  drop  of  blood  from  the 
tail  of  the  same  animal  will  show  numerous  granule 
masses,  at  the  edges  of  which  the  corpuscles  can  be 


U<'ic'lu  rt  11.  DiiHriis  Ri-yniiiiul's  Aniiiv,  iH7_'. 


>.^- 


seen.      The  corpuscles  swell   in  water,  and   become 
pale  :   dilute  acetic  acid  render;-,  them  more  distinct ; 


■  i<;.  1. 


cdi 


they  stain  with  carmine  and   methyl-violet.      The 
corpuscles  are  discoid,   pale,  structureless  (  Fig.  2). 


■ic.  2. 


a     i      c 


J)M      "^MJ> 


and  often  undergo  peculiar  alterations  in  shape, 
elongating  or  i)resenting  two  or  three  fine  hair-like 
extensions.  Tliey  measure  from  ,,',,  to  ^^L^,  of 
an  inch.  1  he  largest  I  have  measured  was  . J— • 
and  the  smallest  are  from  ,,J,,,  to  ^,^,,,.  "^^  "' 
ine  tacts  above  given  are  Irom  my  jjajier  before 
the  Royal  Society  in  1874,  which  was  published  in 
the  Proccediiisrs  for  June  i8th  of  that  year.  A 
considerable  part  of  th;it  communicati(.n  was  taken 
up  with  describing  the  changes  in  form  which  the 
corpuscles  undergo  when  kept  for  some  hours  at  the 
temi)erature  of  the  body,  and  examined  in  blood- 
serum;  but  the  corpuscles  were  described  and  figured, 
and  a  true  explanation  given  of  the  structure  and 
formation  of  Schultze's  granule  masses.  These 
bodies  are  undoubtedly  the  same  as  those  described 
by  Zimmerman'  as  elementary  corpuscles  which  he 
found  when  blood  was  let  flow  into  a  solution  of  a 
neutral  salt;  after  the  subsidence  of  the  colored 
elements,  the  supernatant  serum  contained,  in  ex- 

'  Virchow's  .Aroliiv,  Hd.  xviii. 


'-    i' 


1: 


■I 

;1 


'  / 


i 

I  fi 
i     : 


i! 


traordinary  mimbers,   small,   round,  colorless  cor- 
puscles with  weak  contours. 

In  1877-79,  Hayem,  of  I'aris,  investigated  these 
bodies  very  carefully,  and  by  sj)ecial  modes  of 
l)reparation  and  e.\,.uiination  was  enabled  to  isolate 
them  and  prevent  their  aggregation  int<j  masses. 
He  called  them  hiBmatoblasts  and  believed  that 
they  represented  embryonic  red  corpuscles, 

From  this  time  on,  until  last  year,  little  or  nothing 
new  concerning  these  bodies  is  met  with  in  medical 
literature,  when  in  a  series  of  papers  in  the  Centrai- 
blait  f.  d.  meiiiiiiiischcn    Wisscuschaftiii,  and  moi'e 
fully  the  Noveniber  number  of  N'irciiow's  Archiv 
(Hd.  xc. ),  Prof.  Bizzo/ero,  of  'I'urin,  described  anew 
the  cor])us(  les  and  advanced   important  views  con- 
cerning their  connection  with  the  process  of  throm- 
bosis and  coagulation.      His  account  of  the  corpus- 
cles, which  he  calls  -'Biutpjiittchen"  (blood-plates), 
differs  in  no  essential  ])articular  from  that  wliich  I 
had  already  given,  and  his  figure  of  them  in  a  small 
bloodve.ssei  (  I'!.  V.,  Fig.  2,  Virchow's  Archiv,  Rd. 
xc.)  is  similar  to  my  original  one  reproduced  here 
in  Fig.  I.     The  observati(Mis  upon  the  connection 
of  the  corpuscles  with  thrombr.s  formation  are  novel 
and  important.     When  a  vessel-wall   is  injured,  or 
when  an\-  foreign  body  is  introduced,  tiie  earliest 
observable   jjlienomenon    is    the  collection   of   the 
blood-plates  on  the  wounded  s])ot  or  on  the  foreign 
substance.     The  white  corpuscles  appear  later  and 
r.re  much  less  numerous.     The  blood-plates  rapidly 
change,  becoming  fused  or  united  together  and  con- 
verted into  a  granular  substance,  an"d  this  dissolu- 
tion or  disintegration  ajjpears  intimately  associated 
with  fibrin  formation.     In  a  portion  of  a  vessel  .su- 
tured between  two  ligatures  tiie  blood  remains  fluid 
so  long  as  the  blood-plates  retain  their  normal  form 
and  appearance. 

The  influence  which  Schmidt  and  others  attribute 
to    the  white  corpuscle  in  coagulation,  Bizzozero 


bciieves  is  due  to  these  smaller  elements.     Certainlv 
"o  such  rapid  disintegration  of  the  colorless  .-or- 
puscles  takes  pace,  as  is  spoken  of  by  some  writers. 
I'nder  favorable  conditions  they  may  retain  their  vi- 
tality, as  shown  by  anKeboid  movements,  for  twentv- 
onr  or  thiriy-six  hours  after  withdrawal,  and  ma,,y 
Mours  after  coagulation   has  occurred.     U  freshly- 
drawn  blood  is  whippe  i  with  a  bundle  of  threads, 
the  "blood-plates"  first  adhere  to  them,  and  after- 
wards a  k^v  white  and  red  corpuscles.     If  the  threads 
are  then,  before  fibrin  is  deposited,  washed  in  .salt 
,     solution,  they  will,  when  ,,laced  in  a  suitable  litmid 
(proplastic  of  Schmidt),  i-,,duce  coagulation,  which 
as  Bizzozero  has  shown  by  other  experiments,  can- 
not be  attributed  to  the  few  red  or  white  cor,.uscles 
adhering  to  the  threads.      Several   facts  have  come 
under  my  observation  wliich  corroborate  the  views 
of  the  learned  Italian  professor.     [  have  been  struck 
with  the  density  and  ricliness  of  the  fibrin  network 
III    blood  specimens   in    which  Schultze's   granule 
masses  were  abundant.      As  is  uell   known,  the  dis- 
tinctness  with   which   the   fibrin   filaments  can   be 
seen  in  blood  slides  varies  very  much,  and  I  think 
he  variations  will  be  found  to  have  a  close  connec- 
tion with  the  abundance  or  paucity  of  these  de- 
.nents.     As  one  wat.hes  the  prr.cess  of  coagulation, 
the  filaments  fust  seen  are  invariably  in  association 
vith  small  granules-which  represent  disintegrated 
blood  plates-or  larger  Schultze's  masses.      In  rases 
of  extensive  atheroma  of  the  aorta,    the  thrombi 
which  formin  the  small  breaches  of  the  intima  may 
consist  entirely  of  these  corpuscles,  and  in  aneu- 
Msms   the)-  occur   on   the   surface   of  the   fibrinous 
lamin,^      So    also,   in  the  vegetations  of  endocar- 
ditis,    he,se  little  corpuscles  are  found  asso<:iated 
with  the  librin   layers  so  commonly  deposited   in 
tiie.se  structures. 

So  far  as  I  can  make  out,  the  corpu.scles  here  de- 
scribed are  different  from  the  invisible  corpuscles 


\^: 

( 

i 

■  J 

i 

i 

(' 


I 


'! 


I;  f 


of  !'iuft'ss(ji-  Norris,  of  I>iriiiing1iaiii.  The  origin 
of  the  (oijMisclos  roiiuiiiis  a  inoblcin — one  of  many 
(  onne<'te(l  with  tlie  blood  wliich  await  solution  at 
thr  hands  of  histologists. 

'I'o  conclude:  ist.  TIkic  is  in  mammalian  blooti 
a  tiiiid  corpuscular  element,  one-eighth  to  one- half 
tiie  si/.e  of  the  red  corpuscle.  It  can  be  clearly 
seer:  in  the  bloodvessels  of  the  living  animal  or  in 
the  vessels  of  freshly  removed  bits  of  tissue.  It  may 
be  called  ajipropriately  the  third  (:or})uscle,  or 
"  blood- plate,"  tliough  the  latter  expression  is  not 
a  very  satisfactory  one. 

2d.  In  blood  withdrawn  from  the  vessels  these 
corpuscles  aggregate  together  and  form  the  well 
known  granule  masses  in  which  the  corpuscles 
rapidly  degenerate  and  lose  their  outlines.  These 
masses,  first  de.scribed  by  Max  Scliult/,e,  should  be 
known  by  his  name. 

3d.  There  is  evidence  to  show  that  the  third  cor- 
puscle plays  an  important  /-i^/c  in  coagulation. 


I     i\ 


I'KOFKSS.lR    tIK 


^ 

;    ■ 

f 

' 

' 

i   i 

^ 

ON  SOME  NATURAL  MODES  OF 
CURE  IN  EMPYEMA. 


■  ■'"<"";■,  7"'i^'  ^o/'i,  jssj. 


^  y/ii 


f- !    ■    'V 


BY 


"'ir.LIAM   05..F.:4,    M.O.,  F.RC.P.  ,„«, 


i-KOFHSsoK  '"^''"''"nnrKs^KM^jiciNK 


-■~....,...,,r;-;.-;;^--— -CM. 


f  U(  .\1 


THE  NEW   VORK  MEDICAL  RECO:<U 


I 


I 


OH  SOMI 


Ci|,\ii,i.M|.; 
in  the  trea 
say  tlmt,  In 
af^e  with  a 
lind  very  I" 
your  nttont' 
can  do  in  t 
Ix'ft  to  itst 
r.  hy  jiertoi 
ragm  ;  :,  k 
may  be  abs 
l-erforation 
externallv,  •> 
Sfpticajnn'a 
Amyloid  dt 
Ins|)i!;satioi 
tion  is  pcrh 
cure  may  u 
tlie  al)S()rijti 
einpvema  \v 


in 


s  seiis 


gihi 

I  ft  us  fir 
charged  froi 
report  is  as 

Cask  I,— 


//s 


flm  e,  a  S 


wt 


w  ith  typlioi( 


liUt 


presenli 


;;nune(l  on 
tlic  end  of 


ON  SOME  NATURAL  MODES  OF  CURE  IN  EMPYEMA. 


^> 


-1  I 


("■1,  Nii.KMKv  :   Most  ni'voa  Ii.i'.e    seen   what  . //-/ crui  do 
in  the   treatment   of  empyema,  and  I  am  thankl'iil   to 
say  that,  by  tlie  plan  we  now  follow  of  thorougii   drain- 
af^e  with  a  large  caniila  and  antiseptic  dressinirs,  we  lia\e 
liad  very  fortunate   results  ;  hut    todav  1  wish  to    (all 
your  attention  to  two  c-ises  whieh  illustrate  what  jVa/itre 
<'nn  do  in  the  way  of  cure  in   this  formidable  affection. 
Left  to  itself  an  em]n'enia  may  terminate  as    follows  : 
t.  l)y  jierforation  of  chesi-wall.  of   lung,    or   of  diaph- 
ragm ;   :,  kill  by  septic  or   other  infiuences  ;  and  ;,.  it 
may  be  absorbed   or   dry    uj).     Of  these    three    nicxles 
perforation  is  not  very  common  either  into  the  lung  or 
cMernally,  while  into     the    abdomen   it    is   very   rare. 
Septicajmia  ( laims  no  small    ])roportion  f>f  fatal    cases. 
Amyloid  degeneration  and  tuberculosis  kill  not   ;i  icw. 
Inspissation  of  the  purulent  contents  and  gradual  absorj)- 
tion  is  perhaps  the  rarest  of.-ill  terminations.     .\  natural 
cure  may  take  plac  e    by  jierforation  of  the  lung  or  by 
the  absoiijtion    of  the  ])us.    and  of  the  three   ca»es    of 
emjiyema  whidi  you  ha\e  ha<i  an  opjiortunity  of  stud\- 
ing  this  session,  two  furnish  illustrations  of  these  modes, 
let  us  first  study  the  case  of  the  Swede  who  was  dis- 
charged from  Ward  i  i    a  few   days  ago.     'J'he   ciinicd 
report  is  as  follows  : 

(.'ask  1. — Typhoid  ft'Vir  :  empyeiiia  :  expedoralion  of 

tlic  pus  ;    ifiorery. — Christopher   I .   aged    tweniv- 

tlu(e,  a  Swede,  was  admitted  to  hospital  on  March  26ih 
with  typhoid  le\er.     'J'he  attack  was  moderately  severe, 
but  presented  no  special  leatuves.     'J'he    chest  was  ex 
iiuiined  on  admission,    wiili    negative   results.     Toward 
the  end  of  April  (j8th)  as  d»c  temperature  kept  up,  and 


I  ri 


M 

I  (f  ] 


h 


i-tj  t* 


I    'U 


he  liarl  a  cou!j:Ii  with  sliortncss  of  lurnth,  the  hings 
were  examined,  and  al)solute  duhiess  found  at  tlie  ri^'ht 
base,  extendins;  as  lii^Ii  as  the  spine  uf  the  scapula 
behind,  and  the  toiirth  nh  in  front.  "I'he  breath-sounds  were 
not  au(hbie.  and  both  tact  ileantl  vocal  tVemitiiswcrj  absent. 
A  hy|i odermic  needle  was  inserted,  and  aiioiit  tu-entv 
minims  of  creamy  pus  withdrawn.  J'atient  had  no  chills, 
no  sweatint; :  there  was  usually  an  evening;  exacerbation 
of  tem]jerature,  two  or  three  dcj^ree-^,  only  once  reachini; 
105".  It  was  decitled  to  wait  f  >r  a  week  before  operat- 
inir,  and  ujeanwhile  to  improve  his  general  condition  as 
ftr  as  possible.  ( )n  iNbav  isi.  «vithf)ul  anv  aggravation  of 
sNuiploms,  he  beuan  spilling;  up  pus,  and  in  tlie  course 
of  twenty-four  hours  filled  the  spittoon  (capacity  26  02s.) 
'I'he  counh  A\as  very  troublesome,  not  ])aroxysmal 
and  the  juis  was  brought  up  in  rounded  masses  sur- 
rounded l)y  c'ear  mucus,  /u/  //w.ov  it  looked  hke  pure 
|)us,  but  the  isolated  sputa  resembled  closely  those  of 
<  hronic  phthisis.  -No  clastic  tissue  was  found  ;  i)us 
cells  were  the  only  elements  On  Mav  .•^d  the  area  of 
dulness  was  fmnid  to  have  diminished  considerablv,  and 
at  the  angle  of  tlv  scajMila  bre.ith-sounds  could  be  heard, 
distant  on  tranquil  respiration,  hardiand  distinct  on  d-a']) 
inspiration,  and  these  acconijianied  liy  j\-ry  fine  cripitant 
rahs. 

Yox  r-^arly  tliree  weeks  the  expectoration  rf  piis  con- 
tinued :  the  amount  at  fust  large  (15-22  ozs  )  was  by 
tile  ccth  reduced  to  a  ("ouple  of  ounces  daily.  The 
dulness  gndually  diminishe  1,  rind  l>y  the  13th  a 
comparatively  'lear  note  was  obtained  on  the  jjortion  ot 
the  infra  scapular  area  next  the  spine.  Iheath-sounds 
weak  but  i|'iite  audible  ;  moist  sounds  on  deep  inspira 
tiiin.  il's  gencrd  condition  im])roved  rapidly,  temper- 
ature I)ecame  normal,  and  he  was  discharged  June  4th. 
A  slight  area  of  dulness  remained  in  the  outer  ])arl  of 
the  inlra-scapidar  region.     While  under  observation  a 


loud,   roi 

third  and 

not  at  th( 

the  right 

of  this  pa 

I  may  : 

been  in  tl 

interest  tl 

the  result 

That  ai 

coughed  1 

ledge  of  t 

opment  o 

favorable 

appear  to 

knew  of  il 

empyema 

and  expec 

Traube 

a  Natural 

tion,'  has 

tions,  as  a 

physicians 

Hippocrat 

mistaken, 

physicians 

Greene^  r 

Dr.  R.  L. 

medicine  i 

assistant  V 

butions  to 

zed  this  gr 

There  a 


5 

loud,  rough,  systolic  murmur  developed,  heard  in  the 
third  and  fourth  interspaces  to  the  right  of  the  sternum  ; 
not  at  the  apex  or  at  the  base.  It  was  transmitted  to 
the  right  base,  and  was  tirst  noticed  during  auscultation 
of  this  part. 

I  may  safely  say,  gentlemen,  that  in  no  case  which  has 
been  in  the  wards  this  session  did  we  watch  with  greater 
interest  the  progress .  of  the  disease,  and  we  can  regard 
the  result  with  equal  satisfaction. 

That  an  empyema  may  perforate  the  lung  and  be 
coughed  up  has  been  known  for  centuries  ;  but  a  know- 
ledge of  the  fact  tliat  this  may  occur  without  the  devel- 
opment of  pneumothorax,  and  constitute  one  of  the  most 
favorable  modes  of  termination  ot  the  disease,  does  not 
appear  to  be  very  widely  diffused.  Hippocrates,  indeed 
knew  of  it,  and  in  several  places  speaks  of  recovery  from 
empyema  (after  pneumonia)  by  perforation  of  the  lung 
and  expectoration  of  the  pus. 

Traubel  in  an  article  published  in  1872,  entitled  "On 
a  Natural  Mode  of  Cure  in  Purulent  Pleuritic  Exuda- 
tion," has  called  special  attention  to  the  fact,  and  men- 
tions,  as  a  curious  circumstance,  that  he  alone,  of  all  the 
physicians  who  had  written  on  empyema  since 
Hippocrates,  had  obserxed  it.  In  this  however,  he  was 
mistaken,  for  it  had  not  esca])ed  the  notice  of  the  Irish 
physicians  in  the  palmy  days  ot  the  Dublin  school.  Dr. 
Greene^  narrated  several  cases  of  the  kind,  and  the  late 
Dr.  R.  L.  Macdonnell,  the  first  professor  of  clinical 
medicine  in  this  school,  and  who  was  at  the  time  clinical 
assistant  to  Dr.  Graves,  in  his  important  paper  "  Contri- 
butions to  the  Diagnosis  of  Empyema,''^'  clearly  recogni- 
zed this  group  of  cases. 

There  appear  to  be  two  ways  in  which  an    empyema 


i     (.) 


'l\ln' 


1  Ges.immelti;  Heitrrige,  I!d.  iii.,s.  44,  1878, 

2  Dublin  Metlical  Journal,  vol.  xvii.,  1840, 

3  Ibid.  1844. 


1  ^? 


may  discharge  tlirougli  tlic  lung  ;  first,  by  opening  into  a 
l)ronchus  and  the  foiniation  of  a  fistula  ;  and,  second, 
by  a  local  necrosis  of  the  piilmonnry  iileura.  exposure  of 
the  parenchyma,  and  a  soak.nge  of  the  jjus  through  tlie 
spongy  lung-tissue  into  the  bronchi.  In  the  first  way 
pneuniotliorax  usually  develops  and  aggravates  the  danger. 
When  the  pus  perforates  by  a  large  and  free  opening  the 
patient  may  be  sufTo(  ated  by  the  sudden  gush  of  fluid 
which  is  passed  to  the  tubes  more  rapidly  than  it  can 
be  expectorated.  Several  cases  of  this  kind  are  on  re- 
cord. The  establishment  of  a  bronchial  fistula  may  be 
followed  by  temporary  relief,  hut  permanent  recovery  is 
rare.  In  the  second  wav  the  pus  is  usually  discharged 
without  the  formation  of  pneumothorax,  and  we  must  re- 
gard this  as  one  of  the  most  favorable  modesof  termin- 
aUo'i  in  empyema.  'I'raube^  was  certainly  the  fir.sf  to 
i.'''i,:  a  s.ttisfiictory  exjilannMon  of  the  process,  as  he  had 
fi»  opportunity  of  studying  the  condition  of  the  pleura 
an!  lung  in  one  of  these  cases,  and  found  on  the  lower 
ioiie  an  oval  area  two  and  one-half  by  one  inch  with  the 
pleura  destroved,  and  tb.e  lung-tissue  fully  exposed,  but 
no  direct  communication  with  the  bronchi.  That  ])neumo- 
thorax  does  not  occur  he  explains  on  the  view  that  wiiile 
the  powerful  coughing  efforts  <  ompress  the  chest,  and 
are  sufficient  to  drive  tne  pus  ihrougli  the  exposed  lung 
tissue  into  the  bronchi,  the  affected  side  is  immobile,  or 
nearly  so,  and  the  slight  expan;  ion  during  inspiration  has 
not  force  enough  to  aspirate  air  into  the  pleura. 

Greene,  in  the  ])a])er  already  referred  to,  clearly  dis- 
tinguishes between  the  two  classes,  stating  that  "  in  cases 
of  effusion  a  copious  and  ]»uruleiit  exi)ectoralion  is  a  fre- 
(]uent  accom])aninient,  dejjcnding  in  some  insances  on 
a  fistulous  communication  established  between  the  seat 
of  the  collection  and  a  bronchial  lube,  and  that  when 
such  a  communication  has  taken  place  it  may  be  recog- 

i   I.u';,  cil, 


il  I. 


ni/c(I  liy  Avcllkiunvn  and    cli;ir.\(  tt.ii\iic    si;,'ns.      IJiit    in 

f)ther  iiist.'incfs  tlif  t\|ie(toialiijn  nia\  \>u  KjtiaM    <  onions 

nnd  piiniUnt.  while  all  the  phvMcal  i,i,^ns  of  ,  ,,rii- 

rniinKalii.ti  arc    aj.scnt.    and    where,  ronsc(|i        ,v,    the 

syinptonis  in  (|in.-,ii<)n(  aniiot  be  rderrcd  lo  surii   a   les- 

sum."     In    tiic  latUT  <asc    he    lliouniii.  as   did  also  Dr. 

Miudoniiell.  that   the  ].iis  was  tiie  result   <.i  a  \  icarioiis 

secretion  from  tJie  lnondiial  nieinlitane,  the    ar.tion  of  a 

sort  ot  reciproeitv  between  the    seious  and  huh  ons  stir- 

fnres.      Dr.  Ma<'d(jnnell  draws  a    \ery  projier  distindKin 

hetwet-n  the  syiiiploiiis  in  the  two  :;roii|)s.  wliu  h  1    think 

holds  Kuod  in  the  majority  of  case's.      When  a  i)i()n(  hial 

fistula  IS  established  a  larue  (itiaiility  of   pus  is  e\pt<  lor 

aled  with  \iolent  and  siiddeii    i»aroxvsms    of  c  oui^hing. 

the  (luaiitity  at  limr^  being  so  great    as  to  rause   suffoea- 

tion  ;  whereas   wlieii   no    distiiu  t    fistula  is    established, 

l)iit  the  pus  soaks  througli    the    spongy    hmg  siibsiaiu  r'. 

the  e-tpei  loralion.  though  amounting  to  many  omx  es  in 

twenty-lour  horns,    is  spat    up    graciuallv    and  m    smail 

f|uantities  at  a  time.     This  latter    mode' .ipjiears    to   be 

not    un<()inmon,    it  is  decidedly  more  fre.|iiem  than  the 

ilcvelopmeiU  ol  a    bronchial  fistula,  and    a  large  jiropor- 

tion  ot  the  jialients  ieco\er,  sometimes  with  great  rapuhiv 

We  h.'ivehad  several  instances  in  the  hospital  during  the 

past   tew  years,  and  when  I  mentioned  the  subjei  t  at  the 

Medico-fhinngical  Society,  three  or  lour  instances  were 

narrated  liy  membcvs.     Herfonition  ol  the  bronchus  and 

tlie  establishment  ol]ineumothorax  is    not   always   fatal. 

Attimoni  in  his  essa\.-  ((.Ilectcd    ten  cases   of  recovery 

after  expectoration  of  the  emjiM mn.   and  some  of  these 

\vi  ^e  undoubtedly  (ases  of  broiuhiai  fistula. 

f  Jne  oil.er  point  in  cfinnection  with  this  case  is  wortli 
noting.  \<.u  remember  tiial  when  the  effusion  was  dis. 
appearing,  a  \ery  line  i  repilanl  nile  was    leanl  ^vith  in 


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tipirntion.  at  tbc  angle  of  tiie  sra|)ula.     Tt  was  as  fine  .is 
and  rcscm'jled  closely,  the  i:ineumonic  crei)inis.     In  U\\. 
otiur  cases  of  ])leurisy  I  have    observed    the  same  phe- 
ncnitnon  a>.  the  effusion    was  ahsorlied,   and  was  not  a 
litile    |ni//,led.      Dr.    Macdonnell,    already    referred  lo. 
also  noti'd  tliis,  and  described  it  in  another  l)nper,  "On 
Occiurence  (jf  Cixpltus  in  I,i;ng  after  the  Absorjjtion  ol 
I'leiirilic  I'ffusion.' '^      Is  it,  however,   in   the  lung  ?     I 
mentioned  to  vou  at  the  bedside  that    il   might  he  />ku 
iifi\  due  to  tiie  < cntact  and  friction  of  the  two  surfaces 
after  the  absorjjtion  of  the  fluid,  and  if  so  it  is  in  corrobo- 
ration o(  t]ie\iews  of  I)r  J.  R.    learning  of  New  York, 
v.ho  holds  that  the  pnemnonic  cre|)itus  is  not  a  pulmon 
ary  but  an  interpleural  sound,    due  to  the  friction  of  the 
sti(  ky  surfaces. 

The  patient  before  you.  who  has  been  in  hospital  a 
few  davs,  illustrates  a  very  different  process,  but  one 
which  is  leading  to  a  satisfactory  termination. 

Case  II. — Empyema  of  seven  months.''  standing ,    ah 
'■orptiov.  of  the  flu  d   tenth  retraction  of  the  chest ,    local 
perforations  of  the  pienra  until  subcutaneous    abscesses. — 

A.  i) ,  aged   twenty-three,    from  the  Kastern  'I'own- 

ships.  of  good  stock,  and  always  strong  and  healtliy 
(lives  the  following  history  ;  Quite  well  until  November 
last,  when,  while  lifting  a  lieavy  stone,  he  telt  a  .stabl)ing 
pain  in  the  "ight  side,  which  continued  at  intervals  for 
'v.o  weeks,  during  which  time,  however,  he  was  able  to 
gt  t  about  and  do  work.  He  then  took  to  bed,  got  weak 
and  feverish,  particularly  at  nigiit.  Had  chills,  and  often 
sweated  n  great  deal.  vSIept  on  the  left  side  as  a  rule  ; 
when  on  the  right  the  pain  was  increa.sed.  Had  a  cough 
through  the  wmter  ;  not  much  e.xpectoration.  Lost 
flesh  rapidly.  Has  not  been  confined  to  bed  all  the  time 
but  got  up  and  went  about  when  he  telt  able.     Latterlv. 

3  Ibid,,  1844, 


I    'V 


lie  has  been  hnprovine.  rongii  hasd:';appcarcd,  has  no  fe- 
ver or  sweats,  and  thinks  he  is  gaining  flesh. 

The  history    jjoints   to   some  ciirnnic  cliest    trouble. 
\''hen   stripped  for  examination  lie   jTesents  an  exceed- 
ingly interesting  o])ject    tor  clinical  study.     (General  in- 
spection shows   a  tall.   Ijony  man,    pale  and  emaciated, 
and  tl,    attention  is  at   onc*^-  attracted  to   the    lobsided 
appearance  of  the  body,    dne  to  a  marked  def)ression  of 
the  right  shoulder  and  a  decided  flattening  and  shrinkage 
of  the  right  half  of  the  chest.     Ashe    breathes    (juietly 
you  observe  that  whi'e  the  left  side  expands  the  right  is 
absolutely  immovable,  and  this  is  still  more  marked  w  hen 
he  takes  a  full  breath      the  left  chest  expands  to  an  un- 
usual degree,  the  infra-clavicular  and  mammary  regions 
swelling  out  in  a  striking  manner,  while  the  right  side  re- 
mains  fixed.     I'rnm   behind  the   same   flattening   and 
wr.nt  of  movcmen'.    are   noticeable.     Closer  inspection 
shows  very  nairoA'  mtercostal  spaces    on  the  right  side, 
and  in  the    infra  axillary  region  there  are  two  flat  swell 
ings  in  the  seventh  and  eighth  spaces,  and  in  the  latter, 
also,  a  fresh  cicatrix.     'J'he  apex-beat  can  be  seen  in 
tile  lifih  space  close  to  the  edge  of  'he  sternum.     There 
is  a  rrotcn-oil  rash  on  th.  irom  of  the  chest.     Palpitation 
reveals  more  distinctly  the  narrowing  of  the  intercostal 
spaces  :  the    ribs  do  not  apjiear  hyperl -ophied.      The 
smai:  flat  tumors  in  the  seventh  and  eighth  spaces  flu< 
fuate,  and    do   not    appear   to  communicate  with  eacli 
other.     He  states  thai  one  has  already  disappeared,  and 
a  fourth  was  opened  and  discharged  about  a  spoonful 
of  pus.     He  has  noticed  them  for  a  couple  of  months. 
Tactile  fremitus  is  marked  in  the  upper  part  of  the  right 
side  ;  below   there    is  no  special  intensification.     The 
•edge   of   the   liver   can    be   felt   at   the   costal  border. 
Mensuration   shows   the    right  half  of  the  chest  to  be 
nearly  an  inch  smaller  than  the  left,  not  as  much  as  you 
might    suppose   on    inspection,  but    the   eve   is  in  this 


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matter  very  njit  to  I'C  (U-c  eiveil.  Percussion  u;ives  in 
front,  on  tiie  ri.ulit  sicic.  a  flat  somewhat  tympanitic  note 
as  low  as  the  nipple,  flat  l)eio\v  thi--  and  absoUite  dul- 
ness  hehintl.  I'he  lett  lung  is  everywhere  resonant.  On 
.lusciiltation,  the  breath-sounds  are  absent  in  the  dull 
regions  below,  teeble  in  the  supra-scapular  and  infra- 
claviruLir  regions,  and  on  deep  inspiration  a  lew  rales 
can  be  iieard.  \'ocal  resonance  is  much  intensified  on 
ri.nht  side.  partictiLulv  in  iiliccs.  'The  examination  ol" 
the  abdomen  reveals  nothing  special  ;  the  liver  is  not 
enlarged.  (General  londitinn  during  the  three  davs  he 
has  been  in  ln'-ipiial  has  lueii  good.  I'ats  and  sleejis 
well  ;  h.is  n  >  le\'er  ;  pulse  about  .So.  A  needle  was 
thrust  iiuo  tiie  er;lith  interspace  behind,  but  no  llu'd  was 
obtained.  'J'lH-re  is  l;mdable  jius  in  the  small  flat  tuim)rs. 
He  does  ii<;t  wish  them  opened,  and  returns  home  to- 
day. With  good  food,  b-esh  air,  and  tonics,  he  will  con-  ' 
tmiie  to  im|)r(j\e.  IT  the  small  abscesses  remain,  his 
attending  jiliysii  ian  will  open  them,  but  they  inavdisap- 
liear,  as  one  lui .  already  ilone.  He  will  recover, 
with  a  damaged    lung   aiul    a   si.  -i  side  ;  but  with 

compensatory  enlarueineni  of  ihi.  ..rid  a  gradual  inl- 

])-(jvement  and  distention  ofthi'  upper  ])art  ol'  the  right 
lung  the  res|)irau>rv  area  will  l>e  amply  suHicieiit  tor  the 
purposes  of  an  or  linarv  lite 

As  to  the  diagnosis  m  this  ( ase  -could  you  mistake 
It  for  anything  ci.se  ''  The  onlv  other  aflcction  which 
l^roduces  a  somewhat  s-miliar  condition  is  libroid  phthisis 
or  cirrhosis  of  the  '  ing,  in  which  there  may  be  the  de- 
pressed shoukier,  flattened  and  contracted  chest,  with 
immobility,  dulness,  and  weak  breathing,  but  the  historv 
would  be  one  of  long-standiiv;  lung  trouble,  and 
there  wo.il  1  be  cough,  expectoration,  and  special  aus- 
cultatory si  4ns.  With  the  loi  alabe.-sses  perforating  the 
intercostal  spaces,  the  iliagnosis  m  this  case  is,  at  present, 
casv  enough  ;   but  some  years  hence,  when  these  have 


tlio    retraction, 
mii^ht  not  1)6  so  easy 


ft 

disa])])enred  and  notln'ng  is    IlA   hut 
diilness,  and   feel)le  Ijreatliinj:,   it 

without  a  full  history.  The  condition  of  this  man's 
chest  illustrates  in  another  way  what  nature  can  do  in 
effecting  a  cure  when  an  empyema  is  not  interfered 
with.  'I'he  effusion  has  evidently  been  jirttty  copious, 
and  as  the  weeks  and  months  elnjjsed  became  more 
concentrate  J  and  has  gradually  be.-n  absorbed,  until 
now  there  is  probably  not  more  than  a  few  ounces  left. 
W'nh  the  disapjiearance  of  the  fluid  another  change  has 
gone  on  :  the  flaky  membranous  exudation  covering 
bf)th  layers  of  the  pleura  has  become  organized  and 
converted  into  a  dense  fibrous  tissue  \vhich  may  have 
a  thickness  of  from  half  to  one  inch.  In  the  process 
of  absorption  i)0(kets  of  ])us  may  have  been  left 
between  the  thickened  jileural  membranes,  and  some- 
times this  ])us  becomes  caseous  or  even  cretaceous. 
The  angle  between  .^le  costal  and  dia])hragmatic  layers 
of  the  ]ilcura  may  be  filled  with  a  wedge  of  solid  fibro- 
cartilaginous tissue  which  defies  all  attempts  to  sep.arate  it 
from  lung  or  diaphragm.  'I'he  firmness  of  these  old  pleu- 
ritic membranes  is  extraordinarv,  and  in  the  removal  of 
the  lung,  in  siicii  a  case,  the  only  way  is  to  strip  off  the 
costal  laver  and  take  the  attached  portion  of  diaphragm 
The  dulness  in  front  and  behind  in  this  patient's  r'ight 
side  is  due  chiefly  to  these  thickened  membranes,  and 
corresponding  to  the  se\enth  and  eighth  interspaces  there 
are  small  jjockets  of  pus,  perha])s  isolated,  as  they  often 
are,  and  communicating  by  siiui>es  with  the  small  exter- 
nal tumors,  'i'he  lower  loJ)e  of  the  lung  is  condensed 
and  airless,  ihe  upper  and  middle  lobes,  though  thickly 
coated  with  false  membranes,  ])robal)lv  contain  a  good 
deal  of  normal  and  functionallv  active  tissue.  What  pro- 
duces the  great  deformity  ?  When  a  sero-fibrinous  fluid 
is  alisorlied,  or  after  its  withdrawal  by  asjjiration,  the 
lung  expands,  and  although,  as  you  have  had  several  op- 


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portunitics  of  observing,  for  months  after  there  may  be 
basic  dullness  and  defective  expansion,  there  is  no  re- 
traction.  In  chronic  pleurisy  however,  the  serous  layers 
are  unusually  thickened,  the  false  membranes  organize, 
and  there  is  produced  a  large  amount  of  new  connective 
tissue,  which  gradually  shrinks,  prevents  the  expansion 
of  the  lung,  and  little  by  little  drags  in  the  side,  narrows 
the  intercostal  spaces,  pulls  down  the  shoulder,  may  curve 
the  spine,   and  displace  contiguous  organs,  drawing  the 
heart  over  and  the  liver  up,  until  there  is  presented  such 
a  typical  condition  of  ritrkissemeiit  thoracique  as  exists 
in  this  case.     Although  the  shrinkage  and  condensation 
of  the    organized  membranes  jjlay  the  most  important 
part  in  the  process,  some  share  must  be  attributed  to 
other  agencies,  such  as  posture— the  patient  favoring  the 
affected  side— atmospheric  pressure,  and  muscular  con- 
traction.    Will    this   side  ever  exi)and  again  ?     Not  to 
its  full  extent  or  near  it.     In  time  the  upper  regions  of 
the  lung  will  dilate  more  fully  and  there  will  probabb-be 
some  movement  in    the  anterior  part,  now    absolutely 
quiet,  but  the  deformity  will  remain  and  the  lower  part 
of  the  right  side  will  never   expand.     It  is  true  that  oc- 
casionally a  remarkable  amount  of  exjjansion  may  take 
place  after  a  pkuritis  deformans.     Sir  'J'homas   Watson 
refers  to  two  examples  of  complete  re-expansion  of  the 
side,  contracted   alter  chronic  pleurisy,  but  such  cases 
are  extremely  rare. 

Perforation  of  the  costal  pleura  and  the  formation  of 
a  subcutaneous  abscess  constitute  the  condition  known 
as  empyema  necessitath,  which  is  not  often  seen.  In  this 
instance  the  external  collections  are  small,  and  probably 
connected  with  cncapsuled  deposits  within  the  pleura. 
One  has  already  disappeared,  and  a  second,  which  was 
opened,  healed  rapidly,  and  the  two  which  remain  are 
not  connected  with  each  other,  and  probably  not  with 
any  large  amount  inside.     There  are  two  or  three  points 


c~  01  .1,.  nl,s  ,re  n|,t  1,,  „„  „r  and,.,,,,,  r.™      ,     , : 
tlio  Sinuses  w  11(1  result  run    ;„    ,  "  'L'-o\<.r\.    j  , 

year  or  so  a^o  in  the  u^^iC^ ;^)  ,^'"^'  'f^r^'^  ^' 

-Hi  at  the  autopsy  wJ,;.„;;;^t^;^^;;^;^^^^^ 

antero  lateral  re-ion  (,n  the  Icfr  .i,l    ,i         \      \  '''^ 

111    tmhana   neasstati^  thr    .■v',-,-,i     .     '^'^' ''^" 'i'i"> 
svnclironouslv  with  the  he  rt  .„  ,  /,""'"!'  I'"'^^^^^'^ 

ane.n-isni.       This    i     the   r",  I?     "!''      '''  ""'"'^^""  '"'•'' 

«,a.d,acpu,s.t,on:a;;its^s;\,::L^,.:r;;v7;rM^'' 


■  Tl.o  mistake  h,.„  ,.,ri>c„  from  . he  f,„-t    .1,,,    Dr   UM  I      ,       7 
rcnarkallc casus  of  i,ura-,,:.„ral  r,„U„i„  ,  "''"  ''•'■'  ''"=''^'•■^1  '"'^ 

I  ■tin. 11  pulsallll^'  C-Mipyoiiia. 


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R  E  P  O  II  T 


ON    TUB 


BRAINS  OF  HICHARDS   AND  O'ROIJRKE. 


BY 


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WM.  OSLER,  M.I)..  M.R.c.K,  Lond 
Profe.or  of  .he  I„stitu.,s  of  Medicine  in  McGiU  Unive.i,,  and  Phy.cian 
<o  ti.e  Montreal  General  Hospital. 


HEAD  BEFORE  THE  MEDICO-rmiWHaiaAn  mciET 


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REPRrNTEI)  PROM  THE  "CANADA    MEDICAL  4  SURGICAL  JOURNAL,- 

MAKC'II,   I8WJ. 


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REPORT  ON  THE  RRAINS  OP  RICHARDS  AND 
O'ROURKE. 

Bv  ;VM.  08LKR,  M.D.,  M.U.C.P.,  Lond. 

Professor  of  the  InHtitutcsof  Medicine  in  McOill  University,  and  Physician 

to  the  Montreal  Genera'.  ''uMpitttl. 

i/imil  hr/orr  tlw  M,ilicu-C/,in„v!r<il  Snctvly  „f  M,.„lnnl.) 

Although  Renedikt's  conclusions  have  been  shown  to  be  unwar- 
ranted, and  we  shall  probably  never  be  able,  in  a  given  collection 
of  cerebra  to  pick  out  those  which  have  belonged  to  criminals, 
still,  a  certain  interest  and  value  is  attached  to  the  examination 
of  the  brains  of  individuals  who  have  rendered  themselves 
notorious  by  the  commission  of  great  crimes. 

I.— Richards,  aged  52,  a  large,  p'..verfully-built  man,  mur- 
dered a  comrade  in  the  Eastern  Townships  last  summer.  He 
was  tried  at  Sweotsburg  and  condemned  to  be  executed,  but  the 
evenmg  before  the  appointed  day  he  cut  his  throat  with  a  small 
pen-knife.  He  appears  to  have  been  a  thorough-going  criminal, 
'■  smacking  of  every  sin  that  has  a  name."  Dr.  H.  LeRoy 
Fuller  of  Sweetsburg  kindly  sent  the  brain  for  examination,  and 
furnished  the  following  brief  report  of  Richards  :— "  According 
to  his  own  statement,  he  has  been  a  thief,  a  robber  and  a  liar 
since  ten  years  of  age.  A  portion  of  his  life  was  spent  in  the 
army,  from  which  ho  had  deserted,  and  bore  the  brand  on  the 


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left  side  ;  was  taken  back  and  afterwards  discharged  as  unfit 
from  a  moral  point  of  view.  About  fourteen  years  of  his  life 
were  spent  in  prison,  and  in  addition  to  hard  drinking,  he  was, 
according  to  his  own  account,  much  given  to  women.  lie  may 
have  had  syi)hi!is,  though  there  were  no  external  signs  of  it,  nor 
had  he  any  manifestation  during  the  eight  months  that  he  was 
under  my  observation.  While  here  he  has  been  healthy,  with 
the  exception  of  an  attack  of  diarrhoea  and  occasional  frontal 
headaches.  He  had  a  scar  at  or  near  a  point  corresponding 
externally  with  the  small  spot  of  softening  found  on  the  frontal 
lobe.     This,  he  said,  was  caused  by  the  thrust  of  a  bayonet." 

Brain,—  Organ  weighed  47  ozs. ;  v/as  well  formed  ;  hemis- 
pheres cover  the  cerebellum.  Membranes  ar^'  substance  very 
anaemic.  Membranes  were  normal :  arachnoid  a  little  opaque 
over  the  sulci.     Vessels  empty. 

Fksurex. — In  right  hemisphere,  neither  the  fissure  of  Sylvius 
nor  the  figsure  of  Rolando  joined  contiguous  ones,  though  a 
shallow  groove  connected  the  precentral  with  the  latter.  Both 
the  retro-  and  pve-central  were  well  marked ;  the  latter  was 
longer  than  the  fissure  of  Rolando,  and  passed  deep  into  the  oper- 
culum. A  .short  sulcus  passing  from  the  precentral  fissure,  split 
the  hinder  end  of  the  superior  frontal  gyrus  for  3  cm.  The  sup. 
frontal  fissure  was  separted  by  a  narrow  bridge  from  the  precentral 
fissure,  and,  anteriorly,  sent  three  or  four  secondary  sulci  into 
the  superior  and  middle  gyri.  The  inferior  frontal  fissure  was  well 
marked,  and  had  many  secondary  sulci.  The  interparietal  fissure 
arose  from  the  middle  of  the  retro-central,  and  sent  numerous 
secondary  sulci  into  superior  parietal  lobule  and  angular  convo- 
lution, joined  the  horizontal  occipital,  passed  around  the  angular 
and  united  with  the  first  temporal  sulcus.  Wernicke's  fissure 
was  marked.  The  temporal  fissures  were  normal.  On  the 
meilian  surface,  the  fissure  of  the  corpus  callosum  j)as3ed  deep 
into  and  had  many  secondary  sulci  in  the  precuneus  ;  parieto- 
occipital and  calcarine  fissures  were  normal.  On  the  left  hemis- 
phere, the  fissures  of  Rolando  and  Sylvius  did  not  join  contiguous 
ones.  The  superior  and  inferior  frontal  .'an  out  from  the  pre- 
central, and  were  exceedingly  well  defined.     The  retro-ceutral 


■was  separated  by  a  very  narrow  bridge  from  the  fissure  of  Sylvius, 
and  had  three  deep  branches  in  the  superior  parietal  lobule,  and 
a  deep  and  wide  fissure  in  the  hinder  part  of  parietal  lobe,  which 
joined  the  horizontal  occipital.  The  fissure  of  the  corpus  callosum 
was  interrupted  about  the  middle  of  its  course  by  a  convolution 
uniting  the  gyrus  fornicatus  and  the  first  frontal.  The  parieto- 
occipital and  calcarine  fissures  were  very  deep,  and  ran  to  the 
sassura.  Calcarine  was  normal.  Wernicke's  fissure  was  not 
marked. 

Convolutions.— On  the       ht  hemisphere,  the  frontal  gyri  were 
well  developed,  the  ascending  was  wide  and  large.  The  superior 
was  split  in  its  hinder  part.    The  middle  and  inferior  presented 
nothing  special.     The  orbital  gyri  were  normal.     The  ascending 
parietal  was  narrow.     The  other  pariecal  and  the  occipital  gyri 
presented  nothing  noteworthy.  The  gyrus  fornicatus  was  narrow. 
There  were  five  gyri  in  the  insula.     On  the  left  hemisphere  the 
ascending  frontal  was  largo  ;  the  superior,  middle  and  inferior 
well  defined,  the  first  not  divided  ;  the  middle  ran  out  from  the 
ascending,  interrupting  the  pre-frontal  fissure.     In  the  parietal 
lobe,  the  ascending  was  isolated  and  well  defined.     The  supra- 
marginal  was  large;  the  angular  was  much  fissured.    The  first 
and  second  temporal  gyri  were  divided  by  fissures,  and  there  was 
a  junction  of  the  two  by  a  narrow  bridge.    The  gyrus  fornicatus 
was  split ;  precuneus  well  marked.    There  were  five  gyri  in  the 
insula.     On  the  anterior  angle  of  the  third  left  frontal  jryrus, 
just  where  it  joins  the  orbital  gyri,  there  was  a  superficialpatch 
of  softening,  1  by  1  cm.,  apparently  hemorrhagic,  involving  the 
grey  matter. 

Summari/.—T!he  asymmetry  between  the  convolutions  and 
fissures  of  the  hemispheres  was  very  slight.    The  organ  was  not 
of  the  marked  confluent  fissure  type.     The  secondary  and  cross 
sulci  were  not  excessively  developed.     The  majority  of  the  con 
volutions  were  arranged  in  a  normal  and  typical  manner. 

II.— O'Rourke,  on  the  20th  of  January,  1882,  in  the 
county  of  Nelson,  Ont,  killed  a  farmer  and  his  daughter,  with 
whom  he  had  quarrelled.  He  was  an  uneducated  man,  and  had 
led  an  irregular  life,  going  about  as  a  day  laborer.     He  had 


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served  two  years  in  the  Penitentiary  for  perjury.  Dr  Freeman 
of  Milton  writes  to  me  :  "  lie  had  ilhisions,  believed  that  he  saw 
ghosts,  particularly  that  of  his  mother  and  that  of  a  late  Dr. 
Ford.  He  was  so  timid  that  he  required  cither  a  light  in  his 
room  or  somebody  to  sleep  with  him.  The  reading  of  murder  trials 
to  him  was  his  greatest  treat.  He  left  the  house  of  the  Mahers  in 
the  morning  with  the  most  friendly  feelings,  went  to  an  hotel  and 
got  three  fiints  of  whiskey  ;  returning  to  the  house  about  nine 
o'clock  in  the  evening,  he  bad  some  words  with  Malier  and  his 
daughter,  and  murdered  them  both  with  an  axe,  and  attempted 
to  kill  the  son  on  his  return.  He  told  the  neighbors  that  young 
Maher  had  killed  his  father  and  sister,  but  when  arrested  in  the 
morning  he  confessed.  He  was  indifferent  before  and  after  the 
trial,  and  said  a  person  had  only  once  to  die.  He  never  ex- 
pressed any  remorse."     Insanity  was  jdeaded  in  his  defence. 

Brain. — Received  in  good  condition  from  Mr.  Freeman,  medi- 
cal student.  Hemispheres  symmetrical ;  they  scarcely  cover 
the  cerebellum. 

Frontal  lobes. — ItiyJd  side — The  ascending  branch  of  the 
Sylvian  fissure  passed  up  and  formed  a  precentral  fissure  ex- 
tending to  within  an  inch  of  the  longitudinal  fissure,  completely 
separating  the  2nd  and  ;3rd  frontal  gyri  from  the  ascending 
frontal  convolution.  A  short  pr.?central  fissure  jiasscd  parallel 
to  the  upper  half  of  the  fissure  of  Rolando,  and  was  then  sepa- 
rated from  the  portion  just  described  by  the  base  of  the  second 
frontal  gyrus.  The  first  frontal  fissure  was  well  marked.  A 
secondary  fissure  united  it  in  the  middle  of  its  course  with  the 
lower  prefrontal  fissure,  and  divided  the  2nd  frontal  gyrus  into 
two  portions.  The  second  frontal  fissure  was  well  marked  an- 
teriorly. The  first  frontal  gyrus  was  typical  ;  the  second  was  split 
in  its  posterior  part,  and,  anteriorly,  tlie  lower  division  unites 
with  the  first  frontal  gyrus.  The  third  convolution  was  small. 
The  orbital  surface  was  small,  and  showed  only  four  ladiate 
fissures.  On  the  left  side,  a  deep  precentral  fissui'c  extended 
across  the  hemisphere  without  interruptions.  The  first  frontal 
fissure  was  well  marked  in  the  middle  region,  but  did  not  extend 
into  the  praicentrul.      The  second   frontal  fissure  had   many 


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secondary  branches.  The  ascending  frontal  gyrus  was  large. 
The  first  was  typical  ;  the  second  was  much  fissured,  and,  an- 
teriorly, was  partially  divided  into  two.  The  third  was  normal. 
Orbital  fissures  and  gyri  presented  nothing  notable. 

Parietal  loleH.~lUjhtmle—¥\^ii\nv  of  Sylvius  was  partially 
confluent  by  a  shallow  groove  with  the  first  temporal,  and  by  a 
deeper  one  with  the  retro  central.  The  ascending  branch  passed 
far  up  into  the  frontal  lobe.  The  fissure  of  Rolando  was  not 
confluent.  From  a  deeply  placed,  small  convolution  in  the  middle 
of  the  parietal  lobe,  live  fissures  radiated  ;  three  passed  down, 
of  which  the  anterior  formed  a  short  retro-central  fissure,  which 
joined  the  Sylvian  ;  the  m.ddle  joined  the  first  temporal  ;  the 
posterior  had  two  branches,  one  could  not  be  traced  owin<'  to 
injury  of  the  brain  by  the  saw,  and  the  other  passed  up  and 
joined  a  fissure  in  the  situation  of  the  posterior  part  of  a  nor- 
mal interparietal  fissure.  This  lobe  was  much  and  irregularly 
fissured,  and  the  supra-marginal,  angular  and  superior  parietal 
convolutions  were  greatly  intersected.  The  retro-central  gyrus 
was  well  developed.  Li'ft  stV/f.— Sylvian  fissure  was  not  con- 
fluent ;  fissure  of  Rolando  normal.  The  retro-central  was  marked, 
and  the  inter-parietal  passed  out  from  it  at  right  angles  and 
back  into  the  occipital  lobe,  but  did  not  join  any  of  its  fissures. 
It  had  several  secondary  branches,  which  passed  into  the  angu- 
lar gyrus.  The  retro-central  convolution  was  not  so  well  marked 
on  this  side.  A  small  triangular  convolution  separated  it  from 
the  supra-marginal. 

Teniporo- sphenoidal  lobes— In  the  removal  both  had  suttered, 
particularly  the  right.  So  far  as  could  be  traced,  the  first  tem- 
poral fissure  joined  the  intcr-parictal  and  also  the  Sylvian  by  a 
narrow  groove.  The  third  temporal  fissure  was  marked,  and 
joined  the  calcarine.  The  first  convolution  was  large.  On  the 
left  side,  neither  the  first  nor  the  second  fissures  were  marked 
anteriorly,  but  vertical  sulci  divided  the  convolutions.  The 
hinder  \mvt  of  the  lobe  was  broken.  The  third  was  well  marked, 
and  joined  the  inferior  occipital  and  Wernicke's  fissures. 

Occipital  lobes. — The  saw  had  passed  through  the  lateral  part 
of  the  lobes.     On  ihl-  right  side  there  was  a  small  Wernicke's 


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fissure,  which  united  with  the  horizontal  occipital  and  (so  far  as 
could  be  made  out)  with  the  second  temporal.  On  the  left  side 
Wernicke's  fissure  was  very  marked;  it  joined  the  third  temporal. 

Median  surface. — Left  hemisphere — Calloso-marginal  fissure 
normal.  Parieto-occipital  deep,  and  extended  an  inch  on  the 
convex  surface.  The  calcarine  also  passed  over  the  margin. 
The  continuation  of  these  two  passed  to  the  scissura  hippocampi. 
The  collateral  joined  the  calcarine  by  a  deep  fissure.  The  con- 
volutions were  normal.  The  precuneus  was  deeply  fissured. 
On  the  right  hemisphere,  the  calloso-marginal  fissure  passed  far 
back,  and  was  separated  from  the  parieto-occipital  by  a  narrow 
convolution.  In  its  anterior  half  it  was  double  ;  one  branch 
fissured  the  gyrus  fornicatus  in  the  front  part.  An  ascending 
portinu  formed  the  anterior  boundary  of  the  pruecuneua.  Parieto- 
occipital was  deep  and  marked,  and  curved  over  the  margin. 
The  calcarine  was  not  so  well  defined.  The  united  fissure  ran 
to  the  scissura  hippocampi,  and  also  joined  the  collateral  by  a 
deep  sulcus.  The  gyrus  fornicatus  was  split  into  two  portions. 
The  precuneus  and  the  cuneus  were  much  fissured.  The  cere- 
bellum, pons  and  medulla  presented  nothing  of  note. 

Sum  mar  I/. — The  two  hemispheres  presented  a  marked  asym- 
metry in  the  convolutions  and  sulci.  There  was  no  special  de- 
gree of  confluence  of  the  fissures,  with  the  exception  of  those  of 
the  right  parietal  lobe.  In  both  frontal  lobes  there  was  a  partial 
splitting  of  the  2na  frontal  convolutions,  and  an  approach  to  the 
type  of  four  frontal  convolutions.  The  secondary  sulci  and 
furrows  Averc  unusually  abundant. 


RE-PRIN 


REM 


Prol 

Gentle-^ 

the  last  cl 

case  were 

to  hospital 

during  this 

to  Dispens 

was  103°F 

did  not  pre 

weeks  with 

all  the  app( 

not  grave  ; 

were  two  i 

having  beer 

while  the  fe 

muscles.    A 

course  was  1 

cure  rose  to : 

was  a  consta 

quinine  in  1. 

or  two.     On 

the  highest  1 


KK^KO^OMTHK  "CA^^MKOJC..  .  SHKOXC.  .onH.... 


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REMARKS   ON  CLINICAL  CASES. 

Br  WILLIAM  OSLER,  M.D., 
Professor  of  Clinical  Medicine,  University  of '  Pennsylvania. 

aentlemen,--The  case  of  Typhoid  Fever  which  you  saw  at 
the  last  chn.c  died  on  Monday.  The  prominent  features  of  the 
case  were:  Illness  of  over  three  weeks'  duration  before  comin. 
to  hosptal-fever,  headache,  and  diarrhoea  ;  in  bed  on  and  off 
during  this  period,  but  up  and  about  for  days  at  a  lime.    Came 

ZoT^  '"  '^'  ^'^'  "'^^  ^'^  ^"^"^^"^d-     The  temperature 
jas  103°F.  ;  pulse  90,  dicrotic.     He  was  bright  mentally,  and 
did  not  present  the  appearance  of  a  man  who  had  been  ill  three 
weeks  with  fever.     When  you  saw  him  on  Thursday  last  he  had 
all  the  appearance  of  a  man  with  typhoid  ;  the  symptoms  were 
no.  grave  ;  temperature  not  high  ;  pulse  not  over  100     There 
were  two  unfavorable  features  in  the  ca8e,_the  fact  of  his 
having  been  neglected  for  three  weeks  and  allowed  to  be  about 
while  the  fever  was  on  him,  and  the  nervous  twitchings  of  the 
muscles.    An  unfavorable  prognosis  was  given.   The  subsequent 
course  was  briefly  as  follows :  On  Friday  evening  the  tempera- 
cure  rose  to  105°P.,  and  throughout  Saturday  and  Sunday  there 
was  a  constant  ^  adency  to  elevation,  kept  down  but  feebly  by 
quimne  in  15  and  20  gr.  doses,  and  cold  sponging  every  hour 
or  two.     On  Saturday  the  lowest  temperature  was  101-2°  and 
the  highest  105=.     On  Sunday  it  rose  to  106.2^     He  retained 


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consciousness  in  a  remarkable  and  unusual  manner.  He  took 
stimulants  and  nourishment  every  alternate  hour.  Tlie  diarrhoea 
was  never  troublesome,  but  the  stomach  became  a  little  irritable 
on  Saturday  and  Sunday,  so  that  the  quinine  had  to  be  given  at 
times  by  the  bowel.  It  is  exceptional  for  cases  such  as  these  to 
get  well,  and  when  a  man  walks  into  your  office  complaining  of 
fever,  headache,  and  malaise,  says  he  has  been  ill  a  couple  of 
weeks  and  has  been  fighting  against  it,  and  you  find  his  tempera- 
ture 104°  or  105",  you  may  expect  a  case  of  severity.  As  I 
mentioned  at  the  las*-  lecture,  there  is  no  worse  feature  than 
such  a  history.  The  nervous  or  rather  muscular  twitchings  are 
also  of  evil  omen,  indicating  implication  of  the  nerve  centres. 
They  may  even  amount  to  convulsive  jerkings  of  the  head,  trunk 
and  extremities,  and  I  remember  one  case  in  which  the  muscular 
spasms  were  so  prominent  that  the  disease  was  thought  to  be 
spinal  meningitis.  • 

Heart  Disease :  Action  of  Digitalis. — This  old  man,  aged  75, 
you  also  saw  at  the  last  clinic,  and  he  is  brought  in  to-day  to 
demonstrate  to  you  the  beneficial  effects  of  digitalis  and  rest. 
He  has  mitral  disease,  which  probably  followed  an  attack  of 
rheumatism  in  1854.  On  Thursday  last,  three  days  after  his 
admission,  he  was,  as  you  remember,  very  short  of  breath,  the 
feet  and  abdomen  were  dropsical,  the  pulse  was  small  and  ex- 
ceedingly irregular,  and  the  amount  of  urine  was  reduced.  He 
has  had  10  rri  of  the  tincture  of  digitalis  every  four  hours,  day 
and  night,  and  has  been  kept  (juiet  in  bed.  The  changes  are  : 
1st,  The  pulse  is  slower,  fuller  and  only  occasionally  intermits. 
Those  of  you  who  saw  him  in  the  ward-class  the  day  after  his 
admission  will  recall  the  extreme  feebleness  and  the  irregularity 
of  the  pulse.  2nd,  The  breathing  is  quite  relieved  ;  he  can  lie 
down  comfortably,  and  walking  is  not  an  exertion.  Crd,  The 
dropsy  has  disappeared  entirely  from  the  legs,  and  has  almost 
all  gone  from  the  abdomen,  which,  as  you  see,  is  relaxed,  and 
only  gives  indication  of  a  small  amount  remaining.  4th,  The 
urine  has  increased  from  3  and  3J  pints  to  G  and  7  jiints  in  the 
24  hours.  He  has  been  taking  the  digitalis  ten  days,  5i  in  tli6 
day — not  a  very  large  amount,  but  it  has  served  our  purpose. 


Caisso 

to  Hospiti 

also — or 

to  which  ' 

liable.     'I 

Sus(jueha 

the  piers 

which  the 

Until  Sun 

ence,  bey( 

shall  refei 

feeling  all 

the  left  le, 

the  hip  do 

home.  It  ( 

in  it  was  j 

evening  h( 

power  was 

again ;  w£ 

the  legs  ai 

particular] 

now  quite 

staggers,  i 

shut.     Thi 

gerated  ;  i 

special  foa 

to  what  th( 

his  imperft 

often  abou 

cramp  of  t 

ments.     T 

always  a  f 

with  the  n 

leaving  the 

died  of  th( 

lyzed  in  b 

many  casei 


8 


■     ^^ 


Caisson  Disease. — The  man,  J,  Farrell,  aj;;e(l  80,  who  ciimo 
to  Hospital  yesterday  (17th)  with  a  heavy  cold  in  his  chest,  is 
also — or  rather  has  been — the  subject  of  an  interesting  disease 
to  which  the  workers  in  the  compressed  air  of  the  caissons  are 
liable.     Two  months  ago  he  went  to  work  at  Perryville,  on  the 
Su8(iuchanna,  where  they  are  building  a  bridge,  and  in  sinking 
the  piers  the  workmen  are  in  caissons,  as  they  are  called,  in 
which  the  pressure  may  amount  to  two  or  three  atmospheres. 
Until  Sunday  last  (18 th)  he  had  never  suffered  any  inconveni- 
ence, beyond  occasional  "  bends,"  as  he  calls  them,  to  which  I 
shall  refer  later.     At  4  a.m.  on  Sunday  he  came  up  from  work 
feeling  all  right,  but  before  he  could  got  to  his  boarding-house 
the  left  leg  became  numb,  cold  and  dead,  as  he  puts  it,  from 
the  hip  down,  so  that  he  could  not  walk,  and  had  to  be  carried 
home.  It  did  not  appear  to  be  painful,  but  he  says  the  sensation 
in  it  was  gone,     h  remained  in  this  state  all  day,  but  towards 
evening  he  could  move  it  a  little,  and  on  Monday  morning  the 
power  was  quite  restored.     He  did  not  attempt  to  go  to  work 
again ;  was  too  much  scared  !     There  were  some  pains  about 
the  legs  and  arms  for  a  day  or  so,  and  a  feeling  of  dizziness, 
particularly  if  he  looked  up  or  looked  from  a  height.     He  has 
now  (juite  recovered,  except  that  on  walking,  if  he  looks  up,  he 
staggers,  and  there  is  a  tendency  to  sway  when  the  eyes  are 
shut.     The  patellar  tendon  reflex  on  both  sides  is  a  little  exag- 
gerated ;  no  ankle  clonus ;   skin  reflexes  normal.     No  oiher 
special  features.     He  says  that  the  workmen  are  much  subject 
to  what  they  call  "  bends,"  which,  so  far  as  I  can  make  out  from 
his  imperfect  account,  are  attacks  of  pain  in  the  arms  or  legs, 
often  about  the  joi-its,  but  whether  accompanied  by  spasm  or 
cramp  of  the  muscle  does  not  appear  very  clear  from  his  state- 
ments.    These  attacks  never  come  on  while  in  the  caisson,  but 
always  a  few  hours  or  less  after  they  have  come  up.     So  also 
witii  the  more  severe  attacks ;  they  invariably  come  on  after 
leaving  the  caisson,  never  in  it.     He  states  that  two  men  have 
died  of  the  affection,  and  that  one  man  is  now  in  hospital  para- 
lyzed in  both  legs.     In  the  building  of  the  Brooklyn  bridge, 
many  cases  of  this  curious  disease  occurred,  and  Dr.  Andrew 


.  ]■■'■. 

.-I  ]•  ;'  ■      ii 


\ 

r 

., 

'■■'  n 


;  f!1 


4 

H.  Smith  of  New  York  made  a  special  study  of  it,  and  was,  I 
believe,  the  first  to  j^ive  the  name  by  which  it  is  now  generally 
known.    According  to  his  description,  it  is  characterized  by  pain 
in  one  or  more  of  the  extremities,  sometimes  with  pain  in  the 
stomach  and  vomiting.     There  is  paralysis,  local  or  general,  but 
most  often  in  the  lower  limbs.     Headache,  vertigo,  and  coma 
may  occur.     Cases  may  prove  fatal  with  these  symptoms,  and, 
post-mortem,  congestion  of  the  brain  and  cord  has  been  found. 
In  sinking  the  piers  for  the  bridge  at  St.  Louis,  there  were 
raai.y  cases,  and  there  were  twelve  deaths  among  the  352  men 
employed.     The  disease  has  been  known  to  French  observers 
for  many  years,  and  has  also  been  met  with  in  miners  working 
in  compressed  air,  and  in  sponge  divers  in  the  Mediterranean. 
There  appears  to  be  no  dihiculty,  in  the  majority  of  the  work- 
men, in  standing  a  pressure  of  two  or  three  atmospheres,  and, 
as  a  rule,  no  inconvenience  is  felt  further  than  the  temporary 
pain  in  the  ears,  due  to  the  pressure  on  the  drums,  which  dis- 
appears gradually.  Naturally,  there  is  a  tendency  for  the  blood 
to  be  driven  into  the  deeper  parts,  the  superficial  vessels  are 
compressed,  there  is  less  blood  in  the  skin  and  more  in  the  vis- 
cera.    The  brain  and  cord,  enclosed  in  solid,  incompressible 
cases,  will  also  have  an  additional  amount  of  blood.     But  this 
does  not  appear  to  produce  any  inconvenience,  and  men  can 
work  for  hours  under  a  compression  of  three  or  even  four  atmos- 
pheres.    The  danger  is  in  the  transition  from  a  high  to  a  low 
pressure,  and,  as  this  patient  has  told  us,  the  men  are  never 
affected  in  the  caisson,  but  always  on  coming  up.     The  occur- 
rence of  sudden  death,  or  a  rapid  paralysis,  suggest  haemorrhage 
as  the  cause,  but  it  has  been  shown  by  lloppe-Seyler  that  there 
may  be  a  sudden  development  of  nitrogen  gas  in  the  blood  on 
removal  from  high  to  a  low  pressure  atmosphere,  and  he  attri- 
butes the  symptoms  and  the  fatal  result  to  the  evolution  of  this 
gas,  the  bubbles  of  which  plug  the  capillaries  in  the  lungs  and 
^roduce  dilatation  and  stoppage  of  the  heart.     Bert  states  that 
in  an  animal  under  very  high  i)ressure,  the  blood,  when  with- 
drawn at  low  pressure  of  the  atmosphere,  will  foam  from  the 
rapid  evolution  of  nitrogen.    The  paralysis  is  probably  also  due 


to  this  cause,  and  in  one  case  Leyden  has  found,  15  days  after 
the  onset  of  the  jiaraplegia,  lacerations  in  the  cord,  whicli  he 
attributed  to  tlie  action  of  the  gas  bubbles,  distending  and  tear- 
ing the  capillaries.  Schultze,  in  another  case— death  2^  montiis 
after  the  onset, — could  only  find  disseminated  areas  of  sclerosis. 
This  really  seems  to  give  a  satisfactory  explanation  of  the  cases, 
and  in  this  man  we  may  suppose  that  he  has  had  local  develop- 
ment of  gas  in  the  lumbar  region,  limited  in  extent,  probably 
not  destructive,  but  only  expanding  the  capiliaiies  and  inducing 
a  monoplegia,  which  disappeared  with  the  absorption  of  the  gas. 
Paul  Bert  found  that  if  the  animals  which  had  been  exposed  to 
the  pressure  of  several  atmospheres  were  to  be  kept  alive,  the 
transition  to  the  normal  atmospheric  pressure  must  be  slow  and 
gradual,  so  as  to  permit  of  the  gradual  diffusion  of  the  super- 
fluous gas  absorbed  by  the  blood  under  the  high  pressure.  So 
also  it  is  recommended  that,  on  the  first  onset  of  symptoms  in 
men  working  in  caissons,  they  should  be  submitted  again  to  the 
pressure,  which  should  be  gradually  reduced  to  the  normal 
standard. 

Emphysema— Bronchitis.— 'm?,  man,  J.  S.,  aged  35,  came 
to  hospital  complaining  of  great  shortness  of  breath  and  cough. 
When  stripped,  he  carries,  as  you  see,  the  diagnosis  in  the  form 
of  the  chest  and  the  peculiar  mode  of  breathing.  Inspection 
shows  a  short,  well-nourished  man,  with  a  full,  barrel-shaped 
thorax,  into  which  the  head  seems  set  by  a  very  short  neck. 
Watch  the  peculiar  mode  of  breathing.  The  inspiratory  act  is 
labored,  accompanied  with  more  elevation  than  expansion  o?.  the 
chest-walls,  but  the  abdomen  rises  considerably.  Expiration 
seems  still  more  labored,  and  is  fully  twice  as  long  as  inspiration. 
It  looks  as  if  the  air  were  forced  by  muscular  exertion  out  of 
the  chest ;  and  so  it  is.  With  each  act  there  is  very  audible 
wheezing,  most  marked  with  expiration.  The  finger  tips  are  a 
little  livid,  but  there  is  no  cyanosis  of  the  face.  On  placing 
the  hands  upon  the  chest,  ronchial  fremitus  can  everywhere  be 
felt,  but  most  intense  at  the  rig!,  apex,  in  front.  Percussion 
gives  a  hyper-resonant  i,  over  the  vario-.-  regions,  except 
the    left  base    and    lower  axillary  regions,    where   there    is 


>'\ 


f  /■<  ,  ■ 


II 


u 


r 
I 

! 
I 

I     1 
0     ' 


t    ^ 


>      II 


mmmmmmmit^' 


)     i 


>'!> 


IP.   U'^ 
.1  ■  ! 


In 


6 

defective  resonance.     On  auacultation,  there  are  innumerable 
whistling  and  soiioroua  rrdes  over  the  whole  chest ;  nothing  else 
can  be  heard  with  both  inspiration  and  expiration.     The  high- 
pitched  ones  are  most  prevalent.     There  are  two  places  where 
there  are  special  features.     At  the  right  apex  the  sounds  are 
extremely  hollow,  and  there  may  be  here   eitlier  a  cavity  or, 
what  is  more  likely,  dilatation  of  the  bronchial  tubes  ;  at  the 
loft  base,  with  the  piping  rhonchi,  there  are  many  liquid  riiles, 
and  there  is  possibly  here  some  infiltration— oedema  of  the  lung. 
The  cough  is  most  distressing,  frecjuent,  and  the  sputum  is  got 
rid  of  with  difficulty.     It  is  tenacious,  thick,  and  purulent.    The 
area  of  heart's  dulness  is  covered  by  lung,  and  the  Hver  is 
dci)ressed.     The  points  in  the  history  are  briefly  as  fodows  :— 
He  is  a  jeweller  by  trade,  and  has  used  the  blow-pipe  a  great 
deal  for  15  or  10  years.     He  tells  us  that  sometimes  he  would 
re(iuire  to  keep  up  the  flame  for  16  or  20  minutes,  only  inter- 
mitting enough  to  catch  the  breath.    The  family  history  is  good, 
and  he  was  always  pretty  healthy  until  three  years  ago,  when 
he  was  laid  up  with  a  severe  bronchitic  attack  for  three  months, 
and  ever  since  he  has  been  specially  liable  to  catch  cold,  and 
has  had  four  or  five  spells  of  shortness  of  breath  and  severe 
cough  ;  none  have  been  so  bad  as  the  present  one,  which  came 
on  a  week  ago,  with  fever,  cough  and  dyspnoea.    Two  conditions 
are  here  present :  Emphysema,  a  permanent  and  irreparable 
affection  of  the  lungs  ;  and  Bronchitis,  a  transitory  and  curable 
condition,  upon  which  his  chief  symptoms  now  depend.     Two 
weeks  ago  this  man  could  get  about  satisfactorily,  and,  if  he 
took  it  quietly,  could  go  up  stairs  without  difficulty,  whereas  now 
he  puffs  and  blows  on  the  slightest  exertion.     The  emphysema 
has  no  doubt  been  caused  by  the  habitual  use  of  the  blow-pipe 
in  his  occupation,  and  every  such  attack  as  the  present  one 
leaves  the  lung  in  a  worse  condition  than  before.     Just  now  the 
bronchitis  is  the  main  trouble,  and  the  swol^.a  state  of  the  mucous 
membrane  retards  the  access  of  air  to  the  alveoli,  while  the  loss 
of  elasticity  in  the  lungs  renders  expectoration  very  difficult, 
and  the  cough  is  in  consequence  hard  and  distressing.     On  his 
admission,  he  was  ordered  a  relaxing  expectorant  (chloride  of 


aramonni 
hours,  ai 
poultices 
much  SOI 
the  righ 
symptom 


■4 


aramonium  grs.  x,  with  ipecacuanha  wino  "20  n^)  every  throe 
hours,  and  ah-cady,  after  two  days,  he  is  much  relieved.  Jacket 
poultices,  fraquently  changed,  are  very  useful  when  there  is 
much  soreness  in  the  chest.  The  existence  of  local  trouble  at 
the  right  apex  may  delay  convalescence,  but  the  bronchitic 
symptoms  should  disappear  in  a  few  weeks. 


■''IP. 

^1                     t 

I'      :l! 

I,  I 


m  < 


1- 

^i^:^ 

r 

V. 

;  )■ 

■'  i 

1 

I 

1 

'  \' 

1; 

i 

i 

■C   1 5 


tl  1  J'  ' 

f  Jp    j 

j;i  :  J 

^ 

Ma 

B 

( 

ki'  -  ■     ^ '  ■  - 

m 

I 

.      ■    ; 

1 

1 


rl! 


ISSrt.] 


A  CoxTurn 
Clinical  A 

Till',  cns( 

seizures  fix 

certain  i'vnt 

Tlio  prcs 

its  origin  ir 

tlie  labors  c 

jcot  from  t 

science,     S 

corrohoratii 

study   of  p 

knowlcdjje  ( 

tiiis  nature 

oxpcctud  ns 

years  ago  1) 

or  spasniodi 

associated  w 

lie  suggeste 

nature  of  ai 

tlieniselves, 

convulsion  ( 

presidt'd.     j 

reasonable  t 

in  each  instii 

Avliicli  wlien 

When  OX] 

irritable,  anc 

of  detinite  gi 

was  seen  in 

liim  to  indicj 

brain,  and  an 

bral  cases  bwi 

work  enables 

of  certain  rej 

to  be  in  tlie  i 

fissure  of  Rol 

more  or  less  1 


1 88.-5.] 


Osi.  Kn,  .Tacksoninn  Kpilcpsy. 


/wK| 


81 


^\>n 


AllTlt'I.K   II. 

TUK  caso  hero  n-conl.-.l  iHnstraN.  tl,.-  following  point.  :    Epil..p,ilbrm 
se....n.H  ,rom  a  very  li„.i,.„l  l..,sio„  ;  the  situation  if  tl...  l..„    .  ,      " 
certain  feutufes  in  thu  clinical  i.istory  oC  ti.e  .lis.a.e  " 

TI.e  pn.ont  .loctrin.  of  ccvLral  localisation  may  bo  sni.l   to  i,av.  lut.l 
-.n.,n  ,n  t  c  stn.ly  of  tl.  ,.,rcct.  of  vo.-y  lin.itcd  cortical   IcJ^n 
the  labors  o   Fntscl,  Ilitzi,,  Fcricr,  un.l  otluTs  have  n-niov.,'! 

scu  n  ,t.     St.II,  as  far  as  man  .s  concernc.l,  wl.ih,  admitting  the  arcat  an.l 
orrol.onu,vc  value  of  observations  upon  .Io,s  and  monk:ys,  t^       rl 
st...ly   o     patho  og.cal    cases    offers    the    only    n.eans    wh.L  ,y    po    ,   " 
kM  wie  ,e  can  he  attained.     Year  by  year  in  the  past  decade  .'i.    ,.'^ 
tins  nature  has  been  accumulating,  and  more  important  results  mav  b 
expected  ,.  the  records  become  more  exact  and  scientific.     Fully     Ltv 
years  ago  Dr.  IIughlings-.Tackson.  studying  cases  of  unilaternl  con    N  ,' 
or  spasmodtc  secures  limited  to  one  member,  foun.l  that  they  wen     In 
assocated  w.th  localized  spots  of  disease  on  the  surface  of  the  brai.,       , 
he  ^.ggcsted,  „.   explanation  of  such  cases,  that  the  lesion    S.   T^ 
nature  of    an   .rr.tant   to  the  cells  of  the   gray-cortex,  whici>  disch.       d 
LemseK  es,  so  to  speak,  in  an  irregular  and  explosive  manner,  c.      ' 

pres.ded      As  the  seizures   began   either   in   the  arm,  leg,  or  fhce.  i,  ■  ,s 
reasonable  to  conclude  that  the  portion  of  the  cortex  atfe^t  d  was  d  ,1,., 
.n  each  .nstance,-.  ..,  there  were  actually  centres-motor  in  chan    t^- 
wh.c    when  „.r,tated  in  this  way  caused  the  convulsive  attacks. 

When  experiments  on  animals  den.onstrated  that  the  gray  matter  wa^ 
jM^le  and  ,.at  stimulation  of  limited  areas  was  fallowed  l,y  co  u-Z 
of  dehn.te  groups  of  muscles,  Dr.  Jackson's  suggestion  of  m'otor  t  . 
was  seen  ,n  .ts  true  light.  Ferrier's  observations  on  monkeys  enabled 
urn  to  .nd.cate  approximately  the  homologous  motor  centres  in  the  human 
brajn,  and  an  extraordinarv  in.petus  was  thereby  given  to  the  study  of  e  r  " 
b.al  eases  bearing  upon  h,calizatio„.  The  result  of  the  ten  or  twelve  years' 
work  enables  us  to  speak  with  some  degree  of  positiveness  of  the  fun  tions 
f  certain  regions  of  the  brain.  Thus  the  motor  area  has  been  ascertaiZ 
to  le  ,n  tlu.  nud-rcgion  embracing  ti>e  convolutions  on  either  side  of  the 
fissure  0  Rolando.  Irritative  lesions  of  these  parts  issue  in  .onv.dsio  ! 
more  or  less  limited,  destructive  lesions  cause  paralysis,  local  or  generalized 

'    Read  before  tlie  Medico-Chirurglcal  Society  of  Montreal. 


§ 


1 


f  1 


.,   il 


/ 


32 


O  s  i>  K  u ,  Jacksonian  Epile[)sy. 


[Jan. 


i 

j 

1 

i 

1 

J 

according  to  tlie  extent  of  tlie  disease.  The  otiier  areas  of  tlie  cortex 
cerebri  arc  silent,  quoad  motor  effects  wlien  stimulated,  and  when  destroyed 
do  not  necessarily  induce  paralysis.  With  regard  to  further  specializing 
of  centres  in  the  motor  region,  as  tiir  as  man  is  concerned,  the  analysis  of 
cases  would  appear  to  i)lac(;  the  leg  centre  in  the  upper  part  of  the  central 
convolutions,  particularly  the  part  extending  to  the  median  surface — the 
paracentral  lobule  ;  tiie  arm  and  hand  centre  in  tiie  mid-region  of  the 
central  gyri,  and  the  centres  for  the  face  and  tongue  at  the  lower  end — a 
disposition  in  each  instance  coinciding  more  or  less  closely  with  the  con- 
clusions arrived  at  by  Ferrier  from  his  observations  on  monkeys. 

Dividing  cerebral  symptoms  into  those  accompanied  with  loss  of  func- 
tion  negative,  and  those  characterized  by  excess  of  function — positive, 

the  cases  of  cortical  epilepsy  may  be  taken  as  examples  of  the  latter 
c-rouj).  In  Dr.  Jackson's  phraseology,  the  proximate  cause  of  the 
paroxysm  is  an  abnormally  highly  unstable  condition  of  the  cells  of 
the  gray  matter,  resulting  in  a  sudden  discharge.  "Healthy  movement 
implies  a  liberation  of  energy  or  nervous  discharge  initially  by  cerebral 
cells,  at  any  rate  if  the  movement  be  a  voluntary  one.  A  convulsion, 
that  is  to  say,  a  sudden,  excessive,  rapid,  and  temi)orary  development  of 
movements — many  movements  '  run  uj)'  into  spasm  implies  of  necessity 
a  corresponding,  sudden,  etc.,  discharge."  In  a  local  spasm  only  a  few 
cells  are  in  tiiis  highly  unstable  condition ;  in  severe  seizures  the  sudden 
and  excessive  discharge  of  the  highly  unstable  cells  overcomes,  it  is  sup- 
posed, the  resistance  of  liealthy  cells  in  physiologic.d  connection  with  those 
highly  unstable. 

These  preliminary  remarks  will  enable  the  history  of  the  case  to  be 
more  satisfactorily  followed,  and  I  may  state  too,  the  main  jmints  of  differ- 
ence between  these  epileptiform  seizures  and  true  epilepsy ;  the  slow 
onset,  local  in  ciiaracter,  beginning  in,  or  in  mild  attacks  conlined  to,  one 
liml)  or  a  single  group  of  muscles  ;  the  gradual  extension  until  tiie  side  is 
involved,  o",  in  severe  attacks  the  entire  body;  loss  of  consciousness  late, 
not  early  and  sudden  as  in  true  epih.'psy,  and  lastly,  the  muscular  contrac- 
tions are  clonic,  rarely  or  never  tonic. 

On  November  8,   1883,  I  received  from  Dr.  the  brain  of  his 

daughter  for  examination,  and  with  it  the  following  history : — 

E.  L.  M.,  aged  If)  year.-  9  mo.  "When  sixteen  months  old  fell  on  her 
head  from  a  table  and  appeared  to  be  very  much  hurt,  as  she  cried  violently 
for  a  long  time  after.  She  appeared  to  i)e  (juite  well  for  about  live  montlis, 
when  tiie  left  hand  was  noticed  to  close  firmly,  and  it  secMned  to  pain  her 
a  little  from  the  iirnuicss  of  llie  cutili'aclioii.  Tills  coiitinued  to  increase 
in  severity  and  frecjuency   for  three  months,  when  the  left  leg  became 


similarly  affected,  and  in  two  mon 


ths  more  she  was  confined  to  bed,  and 


the  paroxysms  had  beeome 

general 

all  over  the  boily,  the  moutii  being 

generally  tixed  open  during 
These  spasms  lasted  in  t 

a  spasm, 
his  vioh 

Mit  form  for  about  two  months,  she 

having  as  many  as  eight  or 

ten   m 

an   hour.     There   never   was  at  any 

1885.] 

time  any 

Then  sml 

ran  about 

She  rei 

in  the  sati 

and  then 

and  this  v 

after  the  / 

and  gradu 

To  give 

describe  o 

Suppose 

going  to  h 

hand.)     }i 

down  on  t 

away  in  a 

through  it 

place  liie  c 

After  eii 

and  short! 

the  illness, 

of  tliiU  liin 

ing  each  i\ 

Iiecamc  pe 

ciiair  and  r 

feeble,  and 

as  they  woi 

the  positior 

Last  Chi 

suddenly  cf 

time  she  be 

During  a 

very  much 

quence  she 

remarkable. 

There  we 

the  legs  beci 

after  they  ei 

During  tl 

foot  assumei 

would  rcmo^ 

of  this  (lirly 

i'lu're  wai 

tiie  foot  was 

fluxed  ill  thii 

Just  ;i  \ve( 

incrciising  i\ 

days  there  v 

deatli  tiie  spi 

gostion  of  til 

leiiiperatiire 

very  uuudi  ci 

Just  a  W(>e 

No.  CL 


1885.] 


OsLKu,  Jiicksonian  Epilepsy. 


^ 


33 

time  flJlV  loss  of  PnTl*:r»innc»i*i^-i  1^1  '  t  i 

Ti,on  s,-„i,i,.„iy  th  TviT  ;,;,i,i      r "'r,' '""" "'™"'« "i^g^i'". 

in »»  r"';;  ":;;;r;.:;r„',';,T  :r"™" '"  ■■""  '^"''  "•'"■■""°y '«""-« 

oftli.l  ii„,        ?  "«i''"y*»J"'- years,  mul.lnriiu.  six  weeks 

01  tli.il  nine  ,.he  lay  ;.neon.<cious,  fin.l  iuid  from  lifty  to  ei-|,,v  ;^..>  ,n     In, 

tcul(,aM.l     he  joints  ot  the  fm-ers  would  hen.l  nearly  as  far  h^iekwir  I 

fool'Zll^i'l'^tlSi'l^^n ''"'""''  first  the  n,l,t  an,l  then   the  le.t 
"■'>"M  .  '    o    :  n  "f^Ml  "■  iTI";"""-^'  7  '  ^'l'  '">  =nnount  of  washing 

■lays  .1.,;  ';;;i";:^  ;,r  u  i:r:;;:::4'  ;;:;,,™"'v,r;:' ;-"  '»;■  ?- 

'"7 '■" ;"f «'»'  ""'liii""  "f  ii„.  v,,,«i,  „V,i,„  I,, '•'  '"'■''"' " 

No  c'rU'vn  ■''"; "'"■  '"''■  ""■  "'"■'"•'  '•'■' '""  -'  •■'"  "»•  "> 

JNo.  CLXXVII — Jan.  188.5.  3 


I  P  )l 


(in 


w  / 


f 


'•^: 


34 


OsLEu,  Jiicksoniiin  Epilepsy. 


[Jan. 


liiive  a  post-mortem,  as  she  know  her  case  was  a  peculiar  one,  and  that  it 
mitrht  h(!  of  benefit  to  some  one  else,  and  to  the  medical  profession  in 
particular. 

In  rejily  to  questions,  the  doctor  supplied  the  following  additional  infor- 
mation :  "  The  spasms  always  began  in  the  left  hand  and  nnver  in  the  leg. 
For  about  two  months  at  the  beginning  of  the  illness  the  hand  just  closed 
firmly  for  a  few  seconds,  and  there  was  no  twitching,  but  after  the  expira- 
tion of  the  two  months  it  always  twitched  from  the  onset  of  tlie  spasm. 
Frequently  she  could  be  seen  standing  with  the  hand  closed  and  jerking 
before  the  leg  became  affected,  and  she  had  to  lie  down.  'Die  spasms  '  ere 
never  confined  to  the  left  leg.  When  the  leg  did  become  involved  ilie 
twitching  began  in  the  toes  and  ran  up  the  limb.  At  the  first  the  arm 
alone  was  affected.  When  tlie  spasms  became  unilateral,  the  face  would 
twitcli  and  the  eyes  roll  to  the  convulsed  side.  Tlie  left  arm  though 
feeble  was  not  stiff,  and  in  the  same  useless  state  as  tlie  leg. 

Tiie  clinical  iiistory  may  be  summarized  as  follows :  .lacksonian  epilepsy 
lasting  over  fourteen  years  ;  the  convulsions  beginning  in  the  left  hand, 
at  first  monobrachial,  then  extending  to  the  leg,  afterwards  becoming  uni- 
lateral, and  finally  general,  at  first  without  loss  of  consciousness.  For  the 
first  nine  years  of  the  illness,  remarkable  intermissions  lasting  for  six  or 
seven  months,  once  an  entire  year.  Six  years  after  the  onset  the  left  leg 
got  weak  and  stifle  For  four  years,  the  tenth,  eleventh,  twelfth,  and 
thirteenth  of  the  illness,  the  seizures  frequent,  during  this  period,  six 
weeks'  unconsciousness  in  which  the  spasms  were  very  freciuent,  fifty  to 
eighty  in  the  day.  Ten  months  prior  to  final  attacks  freedom  from  con- 
vulsions.    Intellectual  faculties  unimpaired. 

Brain  examined  on  Nov.  9th  ;  organ  large  and  well  formed;  dura  nat- 
ural ;  iiemispheres  symmetrical;  no  special  cloudiness  of  arachnoid;  I'acclii- 
onian  granulations  small;  large  and  small  vessels  of  pia  mater  eniargcil. 
and  gave  a  very  congested  appearance  to  the  surface  ;  no  adiiesions  of  the 
membrane;  no  s|)ots  of  ojiacity  or  tliickening;  the  pia  mater  stripped  oil' 
exposed  natural  looking  convolutions  of  a  deei)  [)ink-gray  color;  motor 
convolutions  looked  symmetrical,  no  puckering  or  depression;  vessels  at 
base  iiealthy;  right  crus  badly  torn.  The  cord  was  cut  just  at  junction 
with  medulla,  in  the  lateral  as|iect  of  which  tiiere  is  also  a  laceration  : 
tiie  organ  was  sliceil  after  tlie  Pitres  method.  J-'rc-froittal  imd  pcdicii/o- 
frontal  sections  normal.  A  section  passing  3  centimetres  in  front  of  tlie 
fissure  of  Rolando  shows  notiiintr  abnormal.  In  makinji  the  frontal  sec- 
tion  tiie  knife  met  witli  increased  resistance  on  the  rigiit  side,  and  the 
section  whicii  [lassed  through  the  ascending  frontal  convolution,  exactly 
2  cm.  in  front  of  the  fissure  of  Rolando,  exposed  a  firm  fibrous  mass 
occnpying  the  upper  part  of  this  convolution  in  tht;  superior  fasciculus  of 
white  fibres.  It  mt'asured  14  mm.  in  width  l)y  1.")  nun.  in  vertical  lengtii, 
was  8  mm.  from  the  surface  towards  the  longitudinal  fissure,  10  mm.  from 
the  top  of  the  convolution  at  the  margin  of  the  long  fissure,  and  1 ")  mm. 
from  I  he  external  surl'ace.  It  ran  up  to  the  gray  matter,  but  did  iiul 
ap[)ear  to  involve  it  except  towards  the  median  uirfiice. 


1885.] 


18B5.]  OsLER,  Jaeksonian  Epilepsy.  35 

In  a  section  7  or  8  mm.  beliind  tha  fronln/  tlie  mass  was  still  visible  as 
a  small  romiil  piiekere.l  area,  sitnatcil"  just  at  tlie  e<l;re  of  the  irray  matter 
at  the  bottom  of  a  sulcus  passinj,'  into  the  asc.  frontal  from  the  fissure  of 
Kolando,  about  1")  mm.  from  the  lou^'itiidinal  fissure.  It  exteiuled  to 
within  4  or  .")  mm.  of  the  tissi.re  of  Koiando.  Thus  the  entire  mass  was 
witl>in  the  upper  end  of  the  ase.  frontal  ^ryrus,  bavin;:  an  antero-posterior 
extent  of  about  17  mm.,  and  a  vertical  diameter  of  lo  or  IG  mm.,  almost 
entirely  within  the  white  substance,  but  bordering  on  the  gray  matter  at 
several  places. 

Unfortunately  the  torn  state  of  the  crus  and  medulla  made  it  impossi- 
ble  to  trace  any  descending  sclerosis  in  these  parts.  Histologically  tin; 
growth  presented  the  characters  of  a  tirm  glioma,  consisting  of  1st,  and 
chiefly,  a  dense  felt-work  of  fibres,  in  places  coarse;  and  devoid  of  cell 
elements;  2d,  cells  of  various  sizes,  branched  and  fusiform,  the  processes 
of  which  could  be  directly  traced  in  connection  with  the  fibres.  Towards 
the  peripheral  part  of  the  growth  the  cells  weri-.  more  abundant;  ;5d, 
bloodvessels  pretty  numerous  and  large  considering  the  amount  of  fibrous 
tissue  in  the  mass.  The  growth  shaded  into  the  contiguous  tissue  in  a 
very  characteristic  way,  and  towards  the  gray  matter  th(;re  was  no  sharply 
defined  border,  although  in  tiie  microscoi)ic  sections  it  was  easy  to  see 
where  the  normal  tissue  began,  and  there  was  a  zone  in  wiiich  tlnu'e  were 
scattered  a  number  of  deeply  stained  small  cells  like  leucocytes.  In  most 
of  the  sections  the  ganglion  cells  of  the  contiguous  gray  matter  looked 
normal  and  their  nuclei  took  the  logwood  dye  as  usual.  On  the  side  of 
the  convolution  towards  the  fissure  of  Koiando  the  growth  directly  involved 
the  gray  cortex.  A  study  of  the  sections  did  not  appear  to  bear  out 
Klebs's  view  tiiat  the  ganglion  cells  i)articipate  in  the  growth. 

The  case  is  unusual  in  the  limitation  of  the  lesion  to  one  conv<dution 
and  to  its  fasciculus  of  white  matter,  scarcely  involving  the  gray  substiiuce 
which  is  commoidy  affected  in  cortical  epilei»sy.  The  accurate  localiza- 
tion and  the  remarkable  absence  of  tissue  changes  in  the  innnediate 
vicinity  give  the  case  the  nature  of  an  exact  pliysiologicjd  expeiinieiit. 
It  is  the  rule  almost  for  lesions  causing  epilepiform  convulsions  to  involve 
the  cortex,  such  as  meningeal  thickeinng  and  growths,  exostoses,  gliomas, 
and  other  tumors  of  the  surface.  They  need  not,  however,  directly  affect 
the  motor  zone,  but  may  be  in  the  vicinity,  near  enough  to  excite  irrita- 
tion of  the  centres.  Charcot  lays  down  the  following  rule  for  guidance 
in  this  matter:  AViien  in  the  intervals  of  the  attacks  the  patient  has  not 
any  form  of  iiermanent  paralysis,  the  disease  causing  the  convulsions  is 
in  the  non-motor  zone,  but  when,  on  the  contrary,  the  patient  is  paralyzed 
in  the  intervals,  either  monoplegic  or  paraplegic,  we  may  conclude  that 
there  is  a  desa-uctive  lesion  of  the  motor  area,  more  or  less  limited.  For 
example,  a  lesion  at  the  base  of  the  second  frontal  convolution  mi<dit  irri- 
tate the  contiguous  motor  cells  of  the  arm  centre  in  the  ascending  fVonial 
and  produce  epileptiform  seizures  without  any  permanent  paralysis  ;  or,  if 


li:'" 


1 

■'  '  I   '          : 

;  J:, 

^  u      1  ■ 

i- 

'■'"  * 

■ 

f[ 

i  !i-'  ,   ': 

: 

r 
) 
1 


ill  J 


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i     jl 
*    til 


V 


if 


L    i-: 


3G 


OsLKR,  Jacksonian  Epilepsy. 


[Jan. 


ill  tlie  central  part  of  the  motor  convolutions,  iniglit  produce  irritative 
etliM'ts  in  the  leg  and  face  centres  above  ami  below  it,  while  at  the  same 
time  there  was  paralysis  of  the  arm  from  destruction  of  its  centre.  In 
fact  from  cortical  lesions  in  this  region  we  may  have  the  epileptiform 
seizures  without  tlie  paralysis,  or  there  may  be  paralysis  with  the  seizures, 
or  in  some  cases  limited  paralysis  without  convulsions.  In  the  present 
instance  there  was,  with  a  limited  lesion  of  the  motor  area,  permanent 
paralysis  with  contracture  of  one  extremity  and  epileptiform  convulsions. 

in  this  class  of  seizures  the  spasms  may  begin  in  the  hand,  the  face,  ov 
the  foot,  and,  according  to  Jackson,  this  is  the  order  of  frequency,  and,  as 
i\  rule,  tiie  attacks  begin  always  in  the  same  place.  Tiiey  may  be  confined 
to  tlie  one  region — monospasm,  or  may  gradually  extend  until  one  half  ot 
the  body  is  involved — hemispasm.  Facial  and  brad  •  il  monospasm  are 
more  common  than  crural.  Tlie  attacks  may  be  limited  at  first  to  a  grou]> 
of  muscles  in  an  extremity,  or  to  the  entire  limb.  Thus,  in  the  case  of 
the  patient  with  this  disease,  wliich  I  showed  at  the  society  some  months 
a2<>,  there  was  braeiiial  monospasm,  and  in  the  one  under  consideration, 
the  doctor  states  that  the  child  might  be  seen  standing  while  tiie  arm  wa^ 
convulsed. 

The  order  of  spreading  is  important;  it  is  usually  up  a  limb,  but  it  may 
be  in  the  opposite  direction,  and  in  the  event  of  the  monospasm  extending 
it  is  more  common  for  the  face  to  be  involved  with  tlie  arm,  or  vice  rersn, 
and  tlie  leg  with  the  arm,  than  the  leg  with  the  face.  Herefrom  wliat  can 
be  gathered  the  order  of  inarch  of  the  spasm  was  up  !lie  arm,  then  the  leg 
became  affected,  and  afterwards  the  face.  This  is  unusual ;  it  is  more 
com  lion  for  the  leg  to  be  affected  last.  Com[)lete  details,  liowever,  of  the 
precipe  secpience  of  the  spasms  are  wanting.  pAidently  at  first  tiiere  was 
brachial  monospasm,  then  extension  to  the  leg,  and  later  hemispasm  with 
rolling  of  the  eyes  and  affection  of  the  face  muscles.  "Within  six  montlis 
from  the  origin  of  the  trouble  the  seizures  had  become  general,  but  the 
doctor  says  there  was  up  to  this  time  no  lo.-s  of  consciousness,  such  as 
subsequently  took  pla(!e. 

The  extension  of  the  convulsions  to  the  other  side  is  explained  in  one  of 
two  ways;  either  through  tiie  direct  pyramidal  fasciculi  with  which  eacli 
side  of  the  brain  is  connected  in  a  greater  or  less  degree  with  the  same 
side  of  the  boily,  or  more  probably,  on  Broadbent's  t'ieory,tliat  it  is  owing 
to  "  active  conditions  of  the  decussating  fibres  putting  in  action  the  associ- 
ated nuclei  of  both  sides  of  the  cord,  and  then  the  bilaterally  acting 
muscles  of  both  sides  of  the  body."  The  discharge  of  the  nerve  cells  of 
the  cortex  cerebri  excites  the  motor  nuclei  of  the  cord,  and  the  violent 
impulses  p.iss  from  the  spiral  ganglia  to  the  muscles.  Now  it  is  easy  to 
conceive  that  when  the  discharges  are  excessive  and  violent,  the  ganglia 
of  th(!  other  side  of  the  cord  may  be  excited  through  the  commissural 
fibres  which  unite  the  nerve  cells  of  the  anterior  horns. 


188").] 


■€    ■„ 


^^ 


1885.] 


Osi,  KR,  Jiicksonian  Epilepsy. 


37 

The  long  duration,  fourteen  years,  of  a  glioma,  is  not  \vitI.ont  ..arallel. 

Dr.  .Tackson  l.as  nM-orde.l  two  cases,  iu  one  of  wl.icl.  the  fits  lasted  ten, 
and  m  the  other  twelve  years.  Cerel.ral  glioniata  are  benign  growths, 
which  grow  slowly  and  never  produce  metastases. 

_  The  other  feature  of  interest  in  this  case  is  the  light  it   throws  on   the 
situation  of  the  leg  centre.     Ferrier  placed  this  in  monkeys  at  the  "vri  at 
the  upper  end  of  the  fissure  of  Rolan.h.,  and  the  result  of  patholo-ind  in- 
vestigations  in  man  point  to  the  same  situation.     Cases  of  unconu.li<-Mted 
crural  monospasm,  or  monoplegia  are  not  common,  but  in  the  observations 
analyzed  and  collected  by  Ferrier  and  by  Charcot  and  Pitres,  the  lesion 
was  in  each  instance  in  the  upper  part  of  the  central  gyri,  or  in  their  ex- 
tension on  the  median  surface.     When   this  part  is  simply  irritated,  there 
may  be  spasms  beginning  in,  or  limited  to,  the  foot  and  leg  :  when  the  seat 
of  a  destructive  lesion  there  is  crural  monoplegia.     In  their  latest  w.uk,' 
MM.  Charcot  and  Pitres  bring  forward  additional  evidence  in  support 
of  this  view.     In  tlie  case  here  recorded,  the  Hbrous  mass  was  situated 
entirely  within  the  anterior  part  of  the  paraeental  lobule,  limited  in  ex- 
tent, confined  chiefly  to  the  medullary  fibres  of  the  superior  frontal  fasci- 
culus, and  only  touched  the  gray  matter  in  places.     A  point  to  be  referred 
to  is  the  absence  of  the  paralysis  of  the  leg  for  the  first  six  years— for  if 
the  convulsions  and  monoplegia  were  ca-sed  by  the  same  legion,  how  ex- 
plain the  late  onset  of  the  latter?     From  the  fibroid  state  of  the  tunuu-.  it 
migiit  reasonably  be  inferred  that  it  was  originally  larger,  and  had  shrunk, 
but  the  absence  of  [nickering  on  the  surlkce,  and  the  way  in  which  the 
margins  merged  with  the  contiguous  parts,  make  it  probable   that  the 
growth  was  always  small—so  small,  in  fact,  that  at  one  period  of  its  de- 
velopment it  may  have  caused  sufficient  irritation  to  induce  the  convul- 
sions, and  yet  at  the  same  time  not  involved  the  special  fasciculi  of  white 
fibres  to  the  extent  of  producing  weakness  of  the  leg  or  monoplegia. 

In  the  clinical  history,  the  duration,  fourteen  years,  is  the  most 
remark.ible  feature;  it  is  rare  for  cases  of  cortical  epilepsy  to  run  such  a 
prolonged  course.  The  irregularity  of  the  seizures,  the  long  intervals  and 
attacks  of  coma,  which  characterize  so  large  a  proportion  of  these  cases, 
are  phenomena  not  less  difficult  of  explanation  here  where  a  lesion  is 
present,  than  in  cases  of  ordinary  epilepsy  in  which  coarse  alterations  are 
not  usually  met  with. 

'  Revue  de  .\Waecfne,  Octobre,  1883. 


(   i-t 


i!i» 


(IB 

:■    : 

r 

1 

t'    I 


III  i  k 
1  *  r 


Va n.  15 1 1!  n  i:  n .  Intermediate  Hospitals  for  Mental  Diseases.      [Jan. 


Ainici.K  III. 

InTI'.KMKKIATK  HOSIMTAI.S  KOK  TlIK  TliKATM  KNT  OK  Act'TK  ^IkNTAL 

DisKASKS.     By  John  Van  Biiu!i;u,  M.D.,  of  Baltimore. 

TiiK  nervous  .system  lias  of  late  yeai-s  claimed  the  attention  and  study 
of  till'  best  medical  minds  of  all  countries,  and  it  is  now  an  evidence  of  a 
still  fiirtlier  ])roj,rr(ss  in  tliis  direction,  that  mental  diseases  are  no  longer 
allowed  to  remain  in  the  hands  of  asylum-sujierintendents,  but  are  begin- 
ning to  demand  the  care  and  investigation  that  they  undoubtedly  deserve 
from  a  larger  i  nd  more  active  class  of  s[)ecialists.  It  is  by  the  medium  of 
this  development  that  I  have  been  led  at  various  periods,  during  the  past 
five  vears,  to  investigate  the  plan  of  treatment  and  the  management  of 
insane  asylums,  both  in  this  country  and  in  Europe.  And  everywhere, 
both  at  liome  and  abroad,  I  have,  been  impressed  with  the  lonely  and 
isol.'ited  position  which  mental  diseases  hold  in  the  e.stimation  of  the 
geiu'ral  profession,  and  I  may  add,  in  the  opinion  of  those  who  devote 
their  lives  to  the  care  and  treatment  of  insanity. 

Indeed,  it  must  seem  strange  to  any  one  wiio  will  devott;  much  thoiiglit 
to  the  subject,  tiiat  acute  mental  trouble  should  be  segregated  like  small- 
pox, or  some  dreadful  contagion,  far  removed  from  most  humanizing  influ- 
ences, ami  immured  in  more  or  less  tlreary,  but  always  crowded  asylums, 
where  each  patient,  whether  irritable,  excited,  or  convalescent,  is  forced 
into  the  companionshi[>  with  hutatics,  and  where  both  patients  and 
physicians  sutler  the  evil  effects  of  a  moral  and  social  quarantine. 

Now,  although  a  man  either  of  sound  or  unsound  mind  can  endure  the 
enervating  and  dispiriting  effects  of  life  under  the  blighting  influence  of 
a  shadow,  which  makes  humanity  look  hideous,  and  makes  etlbrt  seem 
almost  useless,  yet  it  is  a  question  whether  the  physician  or  patients  are 
at  their  best  in  such  an  atmos[)here,  whetiier  tiie  one  can  progress  and 
prosper  in  his  science,  or  the  other  derive  the  best  advantages  from  a 
delicate  and  careful  treatment. 

It  is,  in  fact,  a  curious  tradition,  which  is  blindly  accepted  by  most 
people,  that  insanity  differs  entirely  from  any  otiier  form  of  disease,  that 
it  must  be  removed  from  sight,  and,  if  possible,  from  remembrance,  and 
treated  only  by  medical  men  wiio  live  within  the  walls  of  an  asylum,  and 
devote  tiieir  lives  to  the  care  of  *lils  class  of  patients.  No  less  is  it  a 
matter  of  general  belief  that  the  institutions  in  which  this  malady  is 
tivated  are  not  hospitals  but  asylums,  tliat  their  use  and  purjiose,  tlioiigh 
known,  is  in  some  way  mysterious,  and  tlieir  existence  stands  outside  and 
apart  from  the  ordinary  ministrations  of  men. 

TiiiT  uncanny  reputation  is  clearly  the  result  of  prejudice,  and  to  some 
extent  the  result  of  the  {)resent  system  of  treating  and  caring  for  a  most 
unfortunate  class  of  sufferers.     It  is  the  remnant  of  that  feeling  which. 


1882.] 

to  a  general 
lie  the  onl\ 
rational  and 
bi-i('lly  and, 
bring  us  bj' 
niciliiiitur." 
150  Mauiso 


(»N    1"(  iiixo 
]M.I!.C.r. 

Lecturer  o 
Mdiitrciil  ( 

'riii:  accii 
the  dog  jiroi 
affect  ion  i)re 
where  the  h 
insure    easy 
iincoininoii, 
to  occur  dnr 
in  America 
give  an  accr 
in  ciiiinectic 
ami  till'  (loin 
I  could  not  1 
ease  was  coi 
it  is  rarely 
iiistanci's  ha 

The  fbllc 
nnisciuns,  jo 
cast's  came  i 

Cask  1.   S 
fur   the  chiss 
Faciiltv,  in  1 
iiionia.      No 
history.     'I'll 

(ll'tllC  I'i^rllt    1( 

graiiildiiughti 
Jlfisji'fal  JU], 

Cask  2.  ( 
All  Italiiin,  a 
Hotel  Dieu 


v> 


1^82.] 


Osi, i; It,   ]'A;liin()C(K'('iis  Disciis<'  in  Amcri.'a. 


47.1 


to  u  jrciionil  i)ViH'tilinncr,  siiu'o  the  conililidii  of  llic  rvcs  iii;iv  oftciitiincs 
Ik-  llic  only  olijcctivc  Mniiitoin  wliioli  will  ciialik'  liini  to  arrive  at  a 
rational  and  scifntidc  diagnosis.  In  I'act,  .inch  consiiliTations  as  wt-i  Iiavc 
liric'dy  and,  consciiiirntly,  Imt  inipcrrfctly  >/\\r\\  in  llic  I'orcuoinu'  ]ia>_'(i.H, 
lirin^  ns  liack  to  ilif  linic-iiononrcd  maxim,  'M^)ui  bciK- distin^tiit,  hcno 
nu'diliitur." 
150  Mauisox  Avji.Mi:,  Nlw  Yoik  C'iiy. 

JL  x// 


nu 


Ainici.r.  XII[. 
On    I'.cniNocorcrs  Diskask   in   Amki.ka.      I'v  Wiri.iA.M   Osi.i:!!.   ]\I.D., 
I\r.l!.(M'.  Jjiiiid,  ;    I'rofcssor  of  file  Iiistiliitcs  ol' Mciliciiic,  .Mcdill  l'nivi'rsit\  ; 
lActnrcr  on   I  Ii!inintliolii;j'y,  Montreal  Vi'teriiiMry  College;    P!iysici:ni  to  the 
IMontreiil  (ieneral  Hospital. 

Till'  uocidcntal  ingestion  of  iIk;  eggs  of  the  tiny  Tcc)i!ii  vchhiococciis  of 
the  doj:  jirodnees  the  most  sei'ious  and  fatal  parasitic  disease  of  man.  The 
atlection  prevails  extensively  in  certain  conntries,  as  Iceland  and  Anstralia, 
where  the  liahits  of  the  ])eople  or  the  relations  of  the  canine  host  to  man 
insure  easy  means  of  cominiinication.  In  Europe  the  disease  is  not 
uncoinnKni,  and  at  any  one  of  the  larirer  (dinics  several  examples  are  sure 
to  occur  during  the  session.  So  far  as  I  know,  {\w  facts  of  its  occurrence 
in  America  have  not  becMi  investigated,  and  the  object  of  this  paper  is  to 
give  an  account  of  an  inipiirv  into  its  prevalence.  I  was  led  to  make  this 
in  connection  with  an  annual  course  of  lectures  on  the  parasites  of  man 
and  the  domestic  aniniids  which  I  give  to  medical  and  veterinary  students. 
I  could  not  ascertain,  from  any  writings  at  my  command,  whether  tht;  dis- 
ease was  common  on  this  continent  or  not.  In  this  si'Ciion  of  the  country 
it  is  rari'ly  met  with,  and  in  the  inspection  of  over  8(10  bodies  only  three 
instances  have  been  fouml. 

The  following  cases,  01  in  nnniher,  have  be<'n  collected  fnun  the 
mnseums,  journals,  transact icuis,  ami  from  private  sources.  The  tirst  three 
cases  came  under  my  own  observation. 

Cask  1.  Single  cyst  in  liver.  Tlie  specimen  was  fouml  in  a  subject  ])rn^•i(]e(l 
fiiv  the  class  in  operative  surgery  (liu'iiig  the  suiuiiier  session  ol'  .Metiill  .Meilieal 
laciihy,  in  1877.  The  man  had  been  a  tramp,  and  dieij  in  the  hospital  of  \)\\v\\- 
nienia.  No  iiiforniation  could  be  ol)tained  from  him  as  to  his  nationality  or  past 
liistuiy.^  'I'he  e\  st  was  the  size  of  a  large  oi'ange,  and  occu))ied  the  ])r>sterior  ])art 
ot'tlie  right  lobe,  in  close  contact,  with  the  diajihraufni,  'i'hi'se  were  dauLditer  and 
gi'anddanghter  cyst,  and  the  scolices  were  well  developed.  Montrtdl  (leiicral 
Jlosp'tal  Jh'portii,  vol.  i.  1S80,  p.  ;;]  1. 


An  It 


vsio   2.    Cysts  in  liver,   spleen,   stomach,   omentinn,   mescMitery,   and  ))el\ 


Uian,  aijed  about 


Hotel  Dicu  on  JNlav  1st,  l.s,s(l,  al 


1   resident  ot'  the  eitv  for  four  vear? 


ter 


an  illness  of  about  six 


Died  in   th 
The  chic 


■  ^1 


'I7r. 


OsM.  It,  Ecliiiiococciis  Disraoe  in  Amorica. 


[Oct. 


1882.] 


.,  ■    i'r. 


syiniiloiiis  wcvcciilMi'iffniciit  of  liver  ;iri(l  splci'ii,  willi  lunliilMr  tiinioiii's  in  aliiloiiiiii, 
in'ri:iii:ir  TcviT,  swciits,  iiliil  ciuMciiition.  Autopsy  ri'vciilcd  tlic  tollowinjr  :  Liver 
<'iil;n';:i'(|  mikI  closely  liuitted  to  the  stom.ieli  and  oiiientnin.  Spleen  projected 
lieyond  tliecr)stid  liorderaiul  readied  nearly  to  the  crest  of  the  iliinn.  Allaelied  to 
tilt'  root  of  tlie  nu'sentery  hy  a  narrow  |)edicle  was  a  lai't'e  |)ear-sli;ipe(i  cvst  the 
Sizooi'tlie  list.  ( )nieiiluin  contained  several  small  ones  and  the  parietal  perilOnenin 
five  or  six,  one  niurli  llatteniMl  and  with  four  sididivlsions.  A  lari;ec\st.  the  sizo 
of  a  cocoa-niit.  fdled  the  entire  pelvis  ami  pushed  up  the  Madder  to  ii  level  with 
the  ui\\v\  and  conipresscil  it  a^'Min-^t  the  anterior  alidominal  wall.  The  livi'r  was 
p-eatly  enlaru'cd  lint  retained  its  shape;  the  nnder  surface  ami  anterior  edn-e  were 
closely  united  (o  the  stomach  and  colon.      The  lel't  lohe  was  as  lar^'c  as   the  ri"ht 

Jiiid  1 tained  two  cysts,  one  in  the  anterior  and  the  other  in  the  posterior  part  ; 

lioth  contained  pus  and  shreds  ot'  eciiinococcns  mcndii'anc.  'i'he  anteiior  cvst  had 
l)erforateil  ilu'  stomach  in  two  jilact's  and  the  dnodemnn  in  one  ;  the  orilices  havinj^ 
.smooth  lirm  ed(.'es.  There  was  a  lar^'e  cyst  lit  the  fnmlns  of  the  stomach,  com- 
pletely within  the  wall  and  covered  hy  a  very  thin  iiiiicosa.  The  spleen  pre- 
sented tln'ce  small  vesicles  at  the  hihis,  and  contained  a  siiiLde  c\st  the  size  ot"  a 
cucoa-nut  everywhere  inclosed  liy  spleen  tissue.      (Unpuhlishcd. ) 

("ask;!.  Obsolete  cyst  ill  liver.  J',iii;lishw(>maii.  aL'ed  alioiit  Ki ;  dead  of  piieu- 
nionia.     Ilooklels  in  the  cri'taceoiis  debris,     (rnpiiblished. ) 

CASh:  ).  Cyst  in  liver.  Xo  history.  Specimen,  with  those  from  Cases  1,  2, 
ami  ;>  in  tlu'  ^luseiim  of  the  Mctiill  .Sledical  .School.      (  rnpublishcd.) 

Cask  .").  Cyst  in  liver.  An  Icelandic  emi;.'rant  woman,  patient  of  Dr.  Hu- 
clian,  of  Toronto.  Cured  by  a  single  asiiiratioii.  Scolice.s  in  the  lluid.  (I'n- 
pnblished.) 

Casi'.  (I.  Cysts  in  liver  and  ])elvis.  Dissectliiir  room  snbiect  ;  female:  To- 
ronto School  of  ;\Iedicine.  Two  cysts  in  the  liver,  one  of  which  had  ruptured 
into  the  intestine.  A  third  was  atlaclu'd  to  tlu'  walls  of  the  jielvis.  (I'npub- 
lislied.     l)r.  1.  11.  Cameron.) 

Cask  7.  Cyst  of  liver.  Yoiin<i  En<rlishwom!in,  patient  of  Dr.  Cameron,  ot' 
Toronto,  who  also  t'lirnislied  the  notes  of  .">  and  (1.      ( Ciipulilished.) 

Cask  S.  Obsolete  cyst  of  liver.  I'-nglishmnn  :  inmate  of  Kingston  liisaiui 
Asylum  for  1  7  years,    ('uimdiaii  .IihuikiI  of  Mtd.  Sciuiices,  Aiiif.  1882. 

Cask  !).  Suppurating  cyst  of  liver,  bursting  into  lung;  cyst  in  s])leen.  J'lnn- 
lishman,  ageil  l'!»,  residi'iit  of  Canada  for  live  years.  Dr.  IJlack,  of  rxbridi:e, 
Out.      (I'npiiblished.) 

Cask  10.  JCeliinoi'Occi  in  brain.  No.  .'jCi;  Army  .Meilical  Museum,  ^\■asll- 
ington. 

Cask  11.  Cyst  in  anterior  edge  of  liver.  From  a  luulatto.  No.  (;.")!  Army 
^Medical  ^Iiiseiim,  Washington. 

Cask  12.  Cysts  in  lung,  spleen,  and  bladder.  Pole,  aLre<l  '10.  lli'iiiarkable 
history.  AV"'  York  Medical  Jiccmd,  Sept.  2,j,  1880.  Nos.  i;M2-4;5-ll  Army 
jMedical  Musenin. 

Cask  Ki.  .Several  cysts  from  Ii\er.  Jar  labelled  V.  C.  '1(J,  vol.  i.  ]\Iuseiiiii 
of  I'nivcrsity  of  I'l'iinsylvaiiiii.  (J.  H.  \\'()od  Cabinet. 

''ask  1-1.    Hydatid  cyst  f)f  spleen.     .Same  collection. 

Cask  l.O.   Liver  with  a  cyst,  probably  hydatid.      Same  collection. 

Cask  K!.  Cyst  in  abdominal  wall.  From  an  lOnglish  sailor  lad.  A\'istar- 
ITorner  collection.  Cniversity  of  I'emisylvania.  I  did  not  see  this  specimen,  but 
I'rof.  Leidy  told  me  it  was  in  the  collection,  lie  stated  also  that  Nos.  1.'!,  11, 
and  l.'i  may  not  be  American  cases,  as  ho  was  under  the  impression  that  the 
,«pi'ciniens  liad  been  imported  from  Paris  by  Dr.  AVood. 

Cask  17.   Cyst  in  liver.     Museum  of  the  reiinsylvania  Hospital,  No.  I.'i82'''". 

Cask  18.  Multiple  cysts  in  liver.  From  a  FreiK'h  lad.  Same  collection,  No. 
1382'', 


1882.]  Osi.Ki!,   Kcliiiiocdociis  Disease  ill  AnuTica.  477 

Casi:  1!I.    Cvsf  of  liver.      Fi-miii  :mi  Iliiliaii,  iiv'eil  r,:,.      Siiiiie  e()li,..ti()ii. 

Cam    I'd.   (■\sl  ill  liver.     New  Yiprk  Hospital  .Miisenm,  X,,.  'x;-j. 

Casi.;  LMMuitlple  eeliiime.MTi;  one  in  iil.(!oniii.i,l  wi.il,  one  on  si.rlMee  of 
hver,  II  h,r,|  |„os,.  „,  ,„.nt„ii..ai  ei.vily,  an,!  a  loMitl.  in  |,ei^is.  No  l,i.,„rv. 
Name  eollrclion,  Xos.  I);i;!-;!.l_;i,-,_;i(;_;j7. 

Cask  -Jl'.   Sinjrl,.  ,.,vst  in  liver.     ISelieviie  Hospital  Mtiseum,  \o.  scr,. 

Cask  L'.'i.    Cvsts  in  liver.      Same  eollccti \o.  SM. 

Cask  -.M.   Cyst  of  liver— siippnralinj;.      .Sanu lleelion,  No.  Siir. 

Cask  2,-i.    J.arjie  eyst   of  liver.      Alusei f  Iniversity  of  New  York    ( I'rof 

l.ooniis).  ^ 

Cask  -Jd.   Cyst  in  liver.      Warren  Anatomical  .Miiscnni,  Harvard,  No.  L'.'iSl. 
Cask  '27.    Kel.inoeoeei  (liseliarjreil  from  iiiLstine.      Same  eollrelioM,   No.  :::::',. 
Cask  •>><.   Cavity  at  apex  of  l,.ft  lm,j,  ,.o,it.,inin-  eel,i,„„.oe,.i.     Same  eolleeiion, 

Cask  •.'!».   Cyst  in  liver,  from  a  sailor  dead  of  phthisis.      Same  .•olleetion.  No. 

Cask  ;((..   Cyst  ..liver.      Dr.   ,Ia<.,l.i.      rrm>sm-li„ns   „f   \r,r    Y„rk  I'utlin. 
Ici/iriif  .\)ctil)/,  vol.  111. 

C.\sK  ;!1.  (V.ts  in   peritoneum,  in  -astro-splenie  epiploon,  attai'lied  to  spleen 
and  hver,  and  one  in  the  pelvis.      Woman,  iut.  2',).      Dr.  .Metealle.      //,/,/. 

CAsKli-i.    Kehhioeneeiis  of  the  eommoi,   hile-diK't.      Old   man,   with  eiilanr,,! 

iverand  deeply  laiindiee.l.      Common  diiet    Moeked  with  a  polvpoid  ti.mo,ir7iie 

Sl/eot   thethiiml.,  wliieli  eontained  three  eeiiinoroeei.      Dr.  AieCready.      /lu,/. 

_    Cask  ;!;f.   Cyst  of  liver.     .Alan,  a-t.  ;)H.      Dr.  Loomis.      Perhaps  the'spe.im'en 

111  museum  ol    I  nivorsity  of  New  York.      //,;,/.  I'tinun 

Cask  ;M.  Cyst  in  reirion  of  liver.     An  Kiiirlishman,  a-e  not  mven.      I'assed 
our  niiarts  ot  mat.na    eontainin^r  ..,|,inoeoee„s  shreds;  also  vomitin-  some  of 
them.      Death  Irom  e.xhanstion.      J)r.  Kevs.      ////,/. 

C.vsi:  ;(,-,.    Cvst  of  ri^rht  l,,!,,.  of  liver.    "  Woman,  a-ed  2!!.      Opened  hv  eai.sti.. 
and  iiK'ision.      Death.      J)r.  .laeohi.      //,/,/.  '  ' 

Cask  ;;(i.  Two  eysts  in  liver,  ri^dit  h.l.e.     (iernian,  sailor.      Dr.  Cory.     //,/,/. 
Cask  ;!7.  Cyst  of  anterior  horder  of  rijrht  iolie.     J)r.  Finnel.      //„',/." 
y/.iVA  "'■  ''''■  ^- '''  '"  "'''"''■     ^^^""'"''^  ''•^'  ''"■i'^i""-r^^<-'Overy.     Dr.    N'an   li.iren. 

Aion:>  claH.'- II;.  '''"'■     ''''"'"'   ''^'  ^''^'''''^    "'"^   i.-sion-reeovery.     J,r. 

C.^.sK  4.1.    Kehinoeoeei  vomited.      A  woman,  vomited  at  dilfereiit  times  ahout 
..       lit  ol  eehMi.,roeei,  supposed  to  eome  from  liver  or  omentum-reeoverv.     J)r. 

JV1(H1/(I   V   iJlt'K  .         Jffiff, 

Cask  42.    Keh 


1.  A.sK  4_'    hei.iiiocom  expectorated  7oin  the  limes.    An  EiMdisIimaii  wh,.     .d 
coiue  irom  Honolulu.     Dv.  Jiernays  (Sen.),  St.  Lonis,  Mo.      cTj.ipuhlishe.t 

I^i^v"  ^'<   ^'W'!'  I'''''^'  ^;'''^'''  '""■^t  "'fo  <•"'  I'o^vel.     German  woman.     J)r 
ISeriiays  (Sen.),  St.  Lonis,  Mo.     (Uniiuhlished.) 


Ca.sk  44.  iMnltiloenlareyst  of  liver.      A  iSavarian.  .-ured  ;^!i.      Dr 


'«)■*■  M(<1.  and  .■^tirn.  J 


(J.  Jon 


null,  Aiii'iist,  Is;; 


Dr.  J>ean.     .S'^. 


Cask  45.  Muitiloeular  cyst  of  liver,  fro 
Cask  4(1.  Cvst  of  li 
of  J'/,i/(i(lc/j,/ita,  vol. 


n  a  nejrro  woman.     Dr.  Dean.     I/,;,/. 


ver.     Man,  aged  32.    Dr.  T 


IV. 


y.son.    Trans.  I)/  Path.  Societi, 


rm 


> 
1 
1   , 

J  ■ 


II' 


iW 


:! 


-17.S 


Osi,  i;  u,   lOcIiiiiiii'di'c'ii.s  Disease  in  America. 


fOet. 


issu'.] 


('as|.:.17.  ICeliiiKicdeci  lit' liver  , Mild  [lelvis.  FrenihiiiMii,  ;i;.'e(l  ,'1:.'.  |)r.  lliilrh- 
iiisim.      //'((/. 

Cask  is.  'rmiionr  in  ri;;lit  li_v]M)eli(iiiilriiiiii  (liver)  tur  several  veiirs.  Kxpeetu- 
ratiiiii  of  eeliiiKieoeei  —  reeiivery.  Wdiiiuii,  a:,'eil  ;i").  Dr.  Aliiiot.  I'msliin  Ma/, 
(iiiil  Siirij,  ,/i)itriiiil,  vol.  111. 

('a>4K  -I!».  ICeliinoeocei  jiasseil  per  reefiitii.  Wcniiaii,  iiLreil  ■_'!!.  I)i'.  Slieraril 
(Mi)liile).      Mnl.  uikI  Siiri/.  I!i jKnli.r,   Is71. 

(-'asi;  .")(».    ICeliiiKicdeei  passed  pel' reelimi.     Hov,  a;.'ed  hi.  UidoTiiiiial  tiiiiioiir 

tor  siiiiie   time.      Svinplcans  ot'  olistriietinii   of  tlie   liowels.  i,eeoM'r\    al'ler  liie 

passaj;e   ot'  a   iarfre   iimiilier  ot'  eeliiiidcoei'i.      I)r.    Siniiiioiis.  Pnriiii-  Mul.  ninl 
■'^11  ri/.  .liiiniKtl,   iMtlt. 

Cask,")].  t'\st  ill  (.'astro-liejiatie  nineiitiiiii.  Woman,  in  liellevne  Hospital. 
Svm|itoms — pain,  janndiee,  ami  jieritonitis.  Ileliiiioeoeiais  cyst  lav  aloiii;  ilie 
eoinmon  duct  and  compressed  it.  Distension  licliiml  tlie  site  of  pressnn,  and 
rnpture  of  the  duet.     l>r.  I'olk.      Mul.  mid  ■'^'urt/.  J'ljxiitcr,  vol.  42,  isso. 

Casi-;  ,">2.  I'a'liinococcns  of  lirain.  >.'()  liistory.  Specimen  in  Cincinnati. 
Authority  ot'  |)r.  llyndnian,  Meilical  ColU'jfc  of  ()hio. 

Cask  a;).  Cvst  in  liver.     No  historv.     Dr.  Ihndman,  of  Cincimniti. 


Casi-;  ,54.'  Cvst  in  fasei,i  ot'iieck,     Dr,  S 


AiKtrifiui  Ml,/.  'J'iiiics,  LsiJl. 


Cask  T),'),'  llchinoeoecus  of  Inng.  F.  (i.  Smilli,  Aml/t  Aiiitiiian  Mtil.-C/iir, 
J!(ri):ir,  l«.").s. 

Cask  ,')(;,'   Cyst  in  liver,     J.  K,  AVeliher.      y,  w  Vor/:  Mc<l.  Times,  IS,-(,",, 

Cask  ;")7.  Cyst  in  tibia,  V.  W .  Welisier.  AV  «•  I'.iiijliinil  .ImtriKil  of  Mi  •!. 
and  Siiri/.,  iMlli, 

C'ask  08.  Cvsts  in  livi'r,  11.  -Vlexander.  llnstnii  Mi  d.  and  Suvq.  Jonrmil, 
]8;i8. 

Cask  ;<t).  Cysts  in  liver  ;  rnptnre  into  peritoneum.  Alan,  aired  ;i:>.  Dr.  (iross. 
]'(it/iiiliji/icul  Andtoinij,  'id  edition,   liS4."),  p.  Ijl'r2. 

Cask  ijo.  Cvst  of  liver,'  I'haritv  Hospital,  New  Oilcans,  Anthoritv,  Dr,  H. 
V,  Ogden. 

Cask  (II,  Cyst  in  liinu'.  cured  hy  incision,  Italian,  aged  ST.  Dr.  FenL'er, 
.i]in.  .Iimrnul  .Med.  ■'^rienci'.i,  Oct,   ISSl. 

The  distribution  of  tlic  cysts  throii^'lioiit  the  orizans  of  the  body  in  tiiis 
series  of  cases  was  as  follows:  Liver  II,  spleen  I,  perit(jiieuin,  onieiitum, 
and  iiiescntcry  7,  pelvis  I,  hinj?  ,'t,  iirain  2,  abdomiinil  wall  2,  stoinaeli  1, 
bladder  1 ,  sulicntaneous  1,  bones  1,  in  common  bile-dnct  I ,  dischar"e(l 
from  intestines  o,  vomited  2,  cxjiectoratcd  2. 

This  list,  imperfect  in  niiiiiy  particulars,  represents  the  tivaiiable  Ameri- 
can cases  of  the  disease.  Doubtless  there  are  many  nnrecorded  instances; 
indeed,  tw:dve  or  more  of  those  here  given  have  not  been  bel'ore  published. 
It  is  evident  that  crhtiiocovcus  lioininls  's  ti  \ery  rare  affection  in  this 
country.  Unfortuniitely  we  cannot  say  positividy  how  many  of  these  eases 
were  truly  American,  /.  e.,  orij^lnated  here,  and  how  many  were  importeil, 
but  in  sixteen  it  is  stated  tlnit  tlus  patients  were  Europeans.  In  the 
majority  the  ntitionality  was  not  given,  but  in  all  probability  at  least  one- 

•  Tliose  three  easci  are  (luotcd  by  Cobbolil  (Parasites,  l«7!t>,  but  Dr,  Hriijluun,  uf 
tlic  Boston  Medical  bibrary,  could  not  fODllrm  the  references. 

'■■  I  iiiiBluid  tlie  notes  kindly  sent  by  i)r,  O^den,  but,  so  fur  ae  I  can  remember,  it 
occurred  in  a  wouiuu,  a  I'oreiffiier. 


^■^ 


18H-.>.] 


Osi.  r.  i;,    Ki'liiiioi'dcnis  Disciisii  in  Anii'ricii. 


•9 


thinl  of  the  cmscs  wciv  ini|i()rl<'.l,  Iciiviii-j;  (inly  al.-.iit  t'oHy  native  ciiscs. 
Tliis  inmumily  may  !..■  di...  liili.T  i,.  scarcity  of  tlic  a.liilt  worm  ur  u,  Hut 
al)scMci-  of  conditions  tiivouraliir  to  tl.c  intccii,,n  of  man.  Tlic  /,i;u'/r  rrh- 
imx'orviis  is  ciTtaiiily  a  raiv  parasit.-.  In  -onic  scores  oC  do-s  u  liicl,  I 
liave  examined  .im'in-  the  past    lilteen  years   1    liavc  never  met  with  a 

siM-cimen   nor  .io    I    know   of  ii,s   det.-ction    i.y  any    A rican   oliMTver. 

Kvcn  in  Knjrlund,  ulieiv  tiie,  diseaM-  is  loieral.ly  common  (.ome  oi'  the 
meiropoiitan  mnsemns  liav<'  IVoin  tweniy-live  lo  ii,irty  s|iecimens  <,!'  <  eii- 
inocoeci),  Col)l)old  states  lliat  tiie  only  e.\am|,|es  ol  tins  Sj.ecies  liiat  iit.i 
knows  of  iiave  l.een  reared  ex|ierinientally.  Tliat  it  is  jircsent  in  dogs  in 
tills  comiliy  t(.  a  .irivaler  extent  tl.an  we  mjolit  snpi.oso  from  tin;  ahovo 
fads  is  shown  hy  tlie  occnrrence  of  echinococci  in  ihe  lower  animals.  In 
casual  visits  to  hatcher  stalls  and  to  the  shamhhs  I  have  ohluined  six  or 
ei-;ht  lar-ie  cchinococci,  and  I  have  the  liver  of  a  cat  with  two  larfje  cvsls. 
One  of  my  slnd.'nt^,  .Mr.  A.  W.  Clements,  ol'  Lawrence,  .Mass.'!  e.xam- 
ined  J7(»  iiogs  at  the  .Ahmtrcal  ahalloii'  and  f. 1  III  animals  alfected. 

I  ilo  not  km)W  of  any  systematic  examinatiim  of  u  iar^a-  imndier  of 
aninials,  hut  Dr.  Dean  writes  that  a  considerahle  proiiortion  of  the  hogs 
slanghtercd  in  Si.  Louis  are  infested,  and  Dr.  (iross,  in  iiis  '•  Pathoh.gical 
Anatomy,"  l«-l,"),  slates  thai  one-lenih  of  the  hogs  ji,  ('incinnali  were  at 
that  time  aileeted,  ami  speaks  of  "whole  droves,  consisting  of  three  ur 
iour  hundred  animals,  all  of  which  were  diseased  in  this  way." 

The  conditions  for  the  devchipment  of  celiinococcus  disease  in  man  are 
cerlaiidy  present  in  the  coinilry,  so  far  as  the  existence  of  the  adnli  worm 
is  concerned,  and  the  immimiiy  which  the  peoi)le  enjoy  may  reasonahlx-  he 
altrihnted  to  the  existence  of  sanitary  arrangements  which  reduce  "to  ii 
minimum  the  risk  of  infection.  Inlike  the  t<r„la  ami  tric/iiiia,  ilu; 
echinocoecus  is  not  introduced  with  ordinary  food  but  is  prohablv  alwavs 
obtained  by  the  driiddng  of  water,  accidentally  contaminated  with  ihe 
leces  of  dog  or  wolf.  A  single  ovum  is  sullicicnt  to  produce  the  most 
serious  damage,  as  it  possesses  such  capabilities  of  growth  that  a  luige  cyst 
may  develop,  containing  daughter  and  granddaughter  capsules,  t^ich'of 
which  lias  many  thousands  of  scolices  or  so-called  hydatid-heuds.  One 
would  thiid;  that  in  the  cattle  and  sheep  ranches  of  the  Western  and  South- 
western States  the  conditions  were  very  similar  to  those  in  Australia  where 
the  attection  is  so  i)revalent.  I  am  informed,  however,  that  the  use  of 
dogs  for  herding  pnr[ioses  is  much  less  common  in  this  country,  bul  there 
are  probably  otiier  tiictors  at  work,  as  some  Australian  authorities  state 
that  the  disease  prevails  in  their  cities  (piite  as  much  as  in  the  country. 

I  liave  to  express  my  thaid<s  to  many  persons  who  have  kindly  aided 
im^  in  collecting  the  tacts  regarding  the  distribution  of  this  atfeclion; 
liarticularly  to  the  curators  of  the  museums  in  Washington,  Philadelphia, 
New  York,  and  Boston,  to  Dr.  Billings  for  access  to  the  MS.  of  the  Sub- 


"  I, 


[I 


)■  ;'jiK 


•if 


;'   ■/" 


.18(» 


II  A  i:  i:  I  s<>\,   Klt!|iliniitiaHi4, 


[Oct. 


jrci  CdtjiId^riH' of  I.ild'iiry  of  Siir;.'i'()ii-(icn(  Till'-  (  Hlic<'.  In  Dr.  N.  S.  Davi;* 
(iml  l)i'.  liiillirlil  of  Cjiiciij^o,  Dr.  lii^rlis  nl'  Diiniii.  D"s.  All  iiihI  Diaii 
ol'  Si.  KdiiIh,  Dr.  Ilymlniaii  <it'  Ciiii'imiali,  Dr.  Alkiiiiioii  of  llnltiiiutrt.', 
Drs.  iMctriilfi'  ami  Sullivan  nf  Kiiiji^idii,  Ont.,  Dr.  I.  II.  Caiiufdii  uf 
Toronto,  iind  Dr.  Iltiiry  tjilibons,  Jr.,  of  San  Frani'i.sco. 


■  m 


f     n] 


AiiTi.  i,i:   XIV. 

A  Cask  oi    Ki.i.i'iiANTrAsis.     M\    Tuns.  T.  S.  IlAiiiiisox,  M.l)., 

Selkirk,  Oriliii'ii>,  C'aiiinlii. 

TllK  following:  oast',  wliicli,  with  sonic  ln'silalion,  I  have  calli'il ''  clc'iilian- 
tia>is,"  is    ill   soiin'   resi>ects  so  iiniiiiic,  llial  I  lliink  it  .slioiilil  lu!  rc|i(irtiil 
1  |iri'-;rrv('(l  in  sonic  journal,  tlio  projicrty  of  tlic  grciit  body  of  the  jiro. 


an 


lession. 

Joiin  A.,  now  nearly  twenty-one  years  of  i\<j:i>,  of  (lenniin  ))arentaiic, 
firtit  came  uiKJcr  my  iiotict;  soini;  eijjjlileeii  years  w^n.  Fallicr  iniiiiiirratcd 
to  tills  cDiiiitiy  wlicii  a  mere  cliild  ;  inoilier,  I  think,  was  iiorii  here  ;  tiicy 
li\ed  all  Iheir  lives  in  a  healthy  rural  district,  fanners  hy  occii])atioii, 
|ierleelly  heallliy,  and  parenlsofa  la r;.'c  family.  The  mother  showed  him 
to  me,  sayin;.'  that  one  of  his  lc;;s  was  too  long.  She  said  that  at  hirlh  he 
was  a  lar;:i',  wcdi-fonned,  heallliy  eliild  ;  that  when  ahoiit  two  years  old  he 
had  the  ri;,dit  foot  slij,ditly  hurl,  so  as  to  make  him  lim|) ;  that  as  she  knew. 


or  thou'jflit  sla/  knew,  the  cause  ot'  his   lainem 


he   made   no  suecial  ex- 


amination of  the  limbs  until  some  four  or  live  months  after  the  injury, 
when  she  found  the  oppositfi  leg,  the  left,  to  be  coiisideraldy  the  longer.  I 
was  at  this  time  away  from  home,  and  she  had  consulted  a  medical  friend. 
J  found  the  boy  was  about   three  years  of  agi',  with  the  left  leg  an  inch 


amt  a   half  or  two  inches  longc-r  than  its  fei 


low. 


The   limbs  were 


,-m- 


mctrical  as  to  the  thighs;  below  the  knee  the  right  leg  was  normal  in 
slia|)e  liut  look<-d  small  ;  the  left  was  much  longer,  and  had  a  ]Mcidiar 
loose,  tlaliby  aiipearance.      T 


lere  was  no  si^rii  ol  a  cal 


The  skill  seen 


to  hang  loosely,  as  if  too  large  for  the  leg,  which,  larger  than  its  fellow  at 
the  head  of  the  tibia,  increased  in  size  to  the  malheoli,  where  the  su|M'r- 
abundaiit  skin  and  cellular  tissue  hung  over  and  covered  a  small  and 
shapely  ankh'. 

1  was  puzzled  by  the  case,  but  finally  concluded  that  there  was  an  arrest 
of  growth  in  the  right  leg,  which  had  been  injured  so  as  to  cause  lameness 


ten  or  twelve  nionihs 


bet 


ore 


but 


[l-i  to  the 


'J' 
leenliar  appearance  of  lluf  lel'l 


leg  ]  could  give  no  o|)inion.     The   mother  told   me  that  the  medical  men 
who  had  seen  the  case  before  nie,  gave  her  the  same  opinion  that  1  had. 
I  saw  the  child  occasionally  on  my  visits  to  the  neighbourhood,  or  when 


tllen(iiii<r  ol!ii-r  nieiiiiirr.s  o! 


th 


<:   lamii 


v;  for,  excepiinsi  tiie  lejr  iroiiidt 


John  was  always  healthy,  and  I  gradually  came  to  tin;  conclusion  that  the 
right  leg  was  normal,  but  that  in  tht'  left  thiM'e  was  not  only  increased 
growth  of  skin  and  areolar  tissue,  but  that  the  tibia  and  fibula  were  enor- 
mously increasing  in  length. 


Lx 


/// 


\  V 


TIIH 


GULSTONIAN  LECTURES, 


o\ 


Malignant  Endocarditis. 

I'KMVKRKl,    AT    THE 

Royal  College  of  Physicians  of  London,  March.  1885. 


\ 


BY 


WILLIAM     OSLLR,     M.D., 

IWcsor   of  Clinical    Mdicino  at    th.    University  of  Pcnsyllania. 


J'liilaiiclpiiia. 


IRcpriaicd  from  il.e  Bkitish  Mbukal  Journal,  March  7.  ,885. 


LONDON : 
THE  URITI.SII  MEDICAL  ASSOCLVTION,  .61A,  STRAND,  W.C. 

i,S.S5. 


f 


*  <;»•■ 


>  I 


'',}  (hf  1 


n^Hi 


r  *  ) 


I   y 


1 

!  II 


1 

}                 i 

I 

I 

l^  ] 


||:>U  I 


THE  GULSTONIAN  LECTURES, 

MALIGNANT  ENUOCAUIXTIS 

I.,  r  ,  "''  ^^'I^^LIAM  OSLEi;    M  D 

^"Ml>  „l  lVm,.-.ylv«,„a,  l.i,ila,|,.|i,|„a. 

LEOTUKE    1. 

'l-'ect.on  wo  nuiy  look  for  T  u  tf ,      /vpin     !'  ""^  ^-^  "«''■■"""'  in  Xt 
your  ,u.nnis.sion,  sir,  I   iw-,   ,t'    'in  h"  ''■''"','"  ^''°  '"f'"''-     AVitl 
interesting  disease  4n(.inllv,\  f''"'  '"  '1'"  case  oC  tliif    ,nl 

^nk..,    nnn  whoso  invo^^u    ,     t"lv;^■'t'"'"^^'>'  ^I-e'late  D 

'^^u.  Joubtless  recall,    and  reca       vf,      ,  "'"'  "*''"  ^"  "'«   to-day 

valvular  allections  of  the  1.^  !'"'';'' '''">' '^'''l  «o  aldy  with 

''"»;. '"u«  I  the  past  twentv-fiv;.,ri  ,":'';'■'"••':  '"  .^''^'"'   "ill  «!.  w 
i-ardiao  disease,  more  liartieuk rlv  fn    ''■''•;'"'"-■  to  ^viden  our  view  of 
'U'J  the  association  of\alvS  i,  II  "  ,nT''''  '",*'"'  '•'"'^■^■t^  "''  '■-  1  o 
J'sorder,  and  the  ,,robahle  cSieioo  •';'/,"  T'"'  ^"''■'  ™"-stit.i.io   al 

f-many,  a  la.^e  au^un    oH     ;!  .il|']  ^^  '""'  '^  ''^^  "^  <i.'  hi 

.ay  assume  that  th,.  etiolo.^  ;'  ;    ' '    '"'',"'  ■•"•'■'"""l.'>t.^.i  ;  and   w 

t  le  .hsease  have  been  fairly"  wH  '• ''"'/  ="'''t""neal  rha  arte  >    f 

"''o"t  as  far  towards  u      11  k^vh'rf '.'!"'''   i""'   ^l''-'*  ««  h  v  ■    . 
--aus  at  our  dis,,„sal  w  H      ", S"    ^    '" '''^;'''°'' ^^  ^he  ord  na  J 

•y-nptonis  a„.l  lesions,  w  r    e^h lei.t     o  'h''".'"  ^''^  -^'-'^''''iptio.   of 
ar^htis;  and  these,  with  th/^  i^';!;^!'!'  °f  "V>'lS"a"t  eniH^ 

tiio  General  Hosptal  at   Mn.,f,.,.i  '■''Penenee  I  have  in, I   ,.f 

'^on.mvhat  more    on  IS.emiv  '      '  ''''I  ^'■'^''^'  '''^^^^  "'^  to  ^''^ 
yet  been  attempted/  '''"  ''''''"''•   >»  «"««  respects,  tLn   has 

'.  ;iituis^?-::a;:!;;";:;rf  ^'^^  -■ «-  -^  -  ^h.  o„t.t 

awite  may  be  ns,.,l   ...;.   1:     "'^.  .■'">'   '■lasMIira(i„n.      Th       '     ■'^^"'^^ 


<-y  I'u  used  to  indicate   tl 


I'loliferation  of,  and 


•■'■vudation  1 


lose  forms  wliicl 


I  are  :u 


>!<•'",  tlic  eiidocaidial 


"esirriiation 
"ii)'anied  bv 
surlare,  with  or 


if  t 


IMlH   .. 


'^  I  I 


H'    I* 


Without  loss  of  .su1)stiiiice,  as  opjiosod  to  cliroiiic,  in  wliicli  tlii'ie  aro 
sci(,'rc)tic  cliani,'os  witliout  vei;otaliuiJs.  Sulidivisiuii.s  of  the  acutu 
I'oriii  have  bucii  arranged  on  an  anatomical  basis,  as  the  terms  jilastio, 
lia|iillary,  verriieose,  I'ungous,  uleerative,  indicate.  On  tlu^  other 
hand,  from  an  etiological  point  of  view,  the  forms  of  endocaiditis  are 
as  numerous  as  the  tlisi'ases  in  which  it  occurs,  and  we  constantly 
liear  the  expressions  puerperal,  rheumatic,  scarlatinal,  etc.  Some 
speak  of  primary  and  secondary  forms  ;  while,  from  a  clinical  stand- 
point, they  are  arranged  in  two  classes,  simple  and  grave.  Ana- 
tomically, there  appear  to  bo  no  very  essential  dilferences  in  the 
various  forms  of  aoiito  endocarditis,  lietween  the  small  capillary 
excrescence  and  tlio  huge  fungating  vegetation  with  destructive 
changes,  all  gradations  can  bo  traced,  and  the  last  may  be  the  direct 
outcome  of  the  lirst ;  the  two  extremes,  indeed,  may  be  present  in  the 
saiue  valve.  They  represent  dill'erent  degrees  of  intensity  of  one  and 
the  same  process.  A  classitieation  of  cases,  based  on  the  ordinary 
macroscopic  characters  of  tiie  inllammatory  proilucts,  into  watery  or 
verrucosc  and  ulcer.itive,  will,  in  many  instances,  group  together  cases 
widely  dill'erent  in  their  clinical  aspects  ;  and,  contrariwise,  a  clinical 
sulidivision  into  cases  of  sim|ile  and  cases  of  malignant  endoeanlitis 
by  no  means  of  necessity  iuipiics  that  tlio  lesiinis  in  the  former  case 
are  all  of  tiie  plastic  or  warty  variety,  and  in  the  latter  of  the  ulcera- 
tive or  destructive.  The  term  ulcerative  has  come  into  very  general 
use  to  describe  the  grave  form,  and  it  expresses  well  an  anatonucal 
feature  ])resent  in  a  large  i)ro[iortion  of  cases  ;  but  in  others  it  is  very 
inajiplicable,  as  there  may  be  no  actual  loss  ol'  .substance,  and  no  more 
destruction  than  occurs  in  the  verrucose  form  :  and,  on  the  other 
hand,  there  m.iy  be  gre.it  destruction  and  ulceration  trom  cause.-i  ol  an 
entirely  dilferciit  nature.  'I'he  numerous  other  terms  emjiloycd — 
seiitic,  infectious,  di[)litlieritic,  mycosis  eiidoeardii,  arteiial  jiyaunia — 
while  eacth  expressing  some  special  fciiture,  and  ,so  tai'  suitable,  have 
never  conic  into  very  geiicial  use.  On  the  whole,  it  seems  to  mo  th:it 
the  names  sim|ile  luni  malignant,  wliich  we  use  often  ti)separate  the 
mildi^r  and  severe  forms  of  many  diseases,  might  a]i[iri)priately  be 
employed  in  desciibing  the  cases  of  acute  endocardilis  ;  the  simple 
lieing  those  with  few  or  slight  symjitoms,  and  which  run  a  favoural)le 
nour.se  ;  the  malignant,  tiu;  cases  witli  severe  (MMistitutional  disturb- 
aui'c  and  extensive  valve-lesions,  wliether  ulcerative  or  vegetative, 
the  term  being  more  clinical  than  anatumii'al. 

JIalignant  endocarditis  occurs  under  tiie  following  conditions  :  1,  as 
a  primary  disense  of  the  lining  membrane  of  tiu;  heart  or  its  valves, 
either  att  leking  persons  in  )>revioiis  good  health,  or  more  often  attack- 
ing the  debilitated   and  dissipated,  or  those  with  old  valve-lesions  ; 

2,  as  a  secondiiry  alfection  in  connection  with  many  diseases,  jiarticu- 
larly  rheumatic  fever,  pneumonia,  scarlet  fever,  di]iiitlieria,  ague,  etc.; 

3,  as  an  associated  condition  in  se]itic  processes,  traumatic  or  puerperal. 
AVe  siiall  discuss  lirst  the  anatomical  characters,  then  the  clinical 
features,  and  lastly  tlie  etiological  and  iiathological  relation.s. 

The  h-fiiuns  of  malignant  endocarditis  are  by  no  nieaii-s  uniform,  and 
may  be  vegetative,  ulcerative,  or  sup[iurativ(^  ;  and  thi^so  various  forms 
may  occur  alone  or  in  combination.  The  belief  that  there  is  always 
ulceration  has  led  to  some  confusion;  and  we  must  recognise  that  there 
are  cases  with  the  clinical  history  of  the  malignant  form  in  which,  yew^ 
mortem.,  the  valvular  condition  has  been  that  of  a  severe  vegetative  or 
verrucose  omlocarditis.  Such  a  case  was  a  lad  aged  11,  a  patient  of 
Dr.  Molson's,  from  whom  I  obtained  the  s])ecimen  which  I  pass  round, 
lie  had  chorea  in  .Inly  ISSO,  the  second  attack.  Rapid  improvement 
and  recovery  under  l''owlcr's  solution,  live  minims  every  four  hours 
hypod'rmically,  took  place.  There  was  a  slight  murmurish  condition 
of  the  first  sound.  Wlnui  vcen  ag.iin  on  March  3r(l,  1881,  the  chorea 
h.id  vet-'irued.  liaviug  begun   ten   days  before.      Th"  patient  improved 


•'•regular,   .oft,  ^ht!        vl    t.  v  ".,  f'  '"  "?"'-^'   '"*^  '     ''''"■'''   ^^■>^'-« 

corpus  strmtuMi.     rde'St^^""^ ,'  'I'"  "^  '■'^''  «"'t^'Mi..^'  in  th.  ri«l,t 
Illustrate  a  n.oro  advance.     .oS  T   **  '''''   "*' ^-''■-   ^^' "■^'^"'■•.s 

tioas  were  large.,  no.^a  In  i"*^  ^'"'  '^'""^  kiml  ;  the  ugeta- 

substanee  was  seen.     Ev       i  i   H  ^V.  'V"""''"'>  ""  •"'^"''l  lo^'^  '>l" 

<  ostruetion  of  endo  ar£ Uis  c  „n Iv  ■  n  ^■'"';^''V"?  ^'"■'•"  '«  «"""^ 
heial  hiye,.;  while  the  ',• ",  o'nt Im  ^ ,  *'"  '•■"^l"t''^'l"'>"  ■'»'«1  Miper- 
valve,  or  ,„ay  invol  •  tl  ;?,  ire  t^H  ,,  "  "m"""''^  ''^^'I''^"  "  *  '"  ^''^ 
witJiout  vegetations  t  're  !  ,],.•''  V,  ^  ■"''"  ^""'"""•Iv  with  or 
rence  of  whi,.h  h  s  .'it'n  the  '";  ^'r?  ''''"l"^''"-y  ol'  the  oeei.r- 

"t  endoearditis.  'IV  loss  <  s  1  n  ''  ""'i"  ""''^'■''^■'1  '^'  ^'"^  '""" 
only  the  endoeardiu  n  or  it  n  lei "  "'"'^  ''?  -^"P^'rll^iM,  involving 
l>erforation  of  a  valve'  of    he    ^  f  ''''  '''..'"^  '''■^"uetiv'e,  Lacling  tC 

valves,  extensive  on  ,Vrowt      ns  ^Z"'  °'  "'"  'T"'^  '^•^^■"'-     <"'  "ie 

'•oneeal  the  nleer  or  7r2.  ,  f,  '  "■'■•""l'""y  the  proeess,  and  may 
well  illustrated  by  t  is'' co  oun.  1  if  '""  '"^'f '^ ''■""i  its  edge,  as  is 
I'''Ocessa,,pearssin,Ivtdeeuiv^^  ^"  '"'''">•   "'-^tant-es,    the 

i"   the  .slightest   fo   n     onh   a   s,  .r    l"^^'^'^^^^^^ 
•scareely   recognisable  ; 'in   othtTs   a'      ''"'    ''^'•''■''°"    '^''^''    r^'>l'»l'.s 
which  half  a  valve   n'lv  be        h!        "O''-'--^'';  "'  •^^''osion    may  go  on  by 

this  drawing)  a  d.:pe;^avtipvi''!-°'"  f''"'"  ''""'' ^'  ('''  ^l'""'"  »' 
■stroying  the  mus  ^u  " ! u^of  tl  '  b'"'  YT"}-  "'"  "'''^■'■^-  -"'^l  J'" 
the  septum   or  of  the  wal     n^t  u    vl  r    '  ''''m'" ''^  I'^'-'^'-'-^fion  of 

features,  however,  ui-on  wl ll/l  cefn  .'tt'"  J^T  '"'"  '''^^  '^""^^•" 
have  seen  supertici,/l  nee.Sic  o  ant  "S£;;"-  „/"  '^^  "-'«"«-■  < 
tions,  circumscribed  i^atebcs  oftlie  Sl„I-  •  "'^''■"^I'on  or  vegeta- 
white  in  colour,  r.^s,.nd  1  .%]  e  ,  ernH  ,  "  "■^'""'''  °P^"l"c' yellow- 
of  the  lunr'  era  i.ortinnnf  1  "  'f'ot'o  plt-mra,  over  a  pyieiiie  infarct 

uiee.  D^K:£tS/;rSehav'r'"Vr'^^^^ 

condition  noted  by  one  or  t  vo   o bs  n^.^   /"/stif  n^  '  '""'  ^''''^ 

suppurative,  in  which  case  the  ,b.e, ,  r  r  i^',  ^^"^  l"'"'"''^'^''*  '"■iv  be 

involved,  and  the  en-loc!:;:!    m  on  "'n  Xatc°    Iv  "'' r  '^'''"^•'"•■■^' 
occurrence  of  small  abscesses  at  the  ba  ev    1^^   cont.gmty.     The 

uncommon,  but  there   are  also     nst    '  ., .   ^-^tensue  vegetations  is  not 
seems  the  initial  .step.     The  com   in  "  ,''''"'!    *'*"   «"Pl'">ation 

outgrowths   is,  perhaps   t  le   m  ?  "*  ulcerative  and   fungating 

tions  vary  a  good  dea    in  'u-,     , .,,  ?"  '^°"'"'"o"-       The  u.g.ta 

white  mLe^  witi"  o  ihc^^d  Se"sm.r"t''''t-  .^"'^  ^-^i^''- 
clot  mlheres,  are  nunuMous  o  tl  e  c  'riv  be  'i',  '''",-,'  *'""  '^^'""'■ 
cences,  with  deep  ]a<"r,a  flss  ires  n,  ^^  •  ^^  cauJillower-excre.s. 
titic  masses.  In  tj  c"l  e.  o  ,  ;,?  liY "'"''  J""^'  l"^"'hilous,  stalar- 
out,  the  effects  of  Irie  on  and  s,,  1  n  1  '"  '"''  "f  "''•  ^'°-^""  Poiuted 
cusp  may  produ..e.  by  co'n  a e  a  who  r';''"''  "''"",/''"'''  '^"  ""'•th' 
along  the  ventricular  w.all  The  ,  sure  1l  "T^^"'  ""^.^™"ths 
other,  and  the  action  of  the  blood  'tend  t,.  I  '  '"'T?  "-'""^^  ^''^'h 
tations,  and  one  can  so,  ueti  les  see  w     ,  '  T^  ^'""'^  ^''^  ^•''Kc- 

oither  entire  or  by  T  ril  ,1  ■'?''"";.  T"'"'  '"'ve  been  torn  ,?ff 
ink  the  force  wi  h  whic h  t ',  ?  '  °*  'h-'utegration.  Consi.le .': 
that  the  soft  veg  tatio  IS  o  „  . y  7^  '""':,  *°«^^'"-"'-'  **  i'^  curious 
hues  of  closure,  can  res  t'  the  entente  *'"^  ^"'"^■'■'^">'  ''"•  ♦!"' 
are  subjected.  Some  ye'.tuion,;..,?  ''"''''''",  ^?  "•'"'■''  they 
S-'ey  or  greenish-yellow  cohju         '  n  "    >'emarkalde  greenish- 

'uaygoon  when  the  -lisease  \nu  h  fV  ,/  .^'T'l'^'^'V"':  ''''•''^'ti"" 
n-ay  take  plaec  in  the  deu't  '''"'','■  l''^"'"!'!.  iu'iuratiou 
--U  unchanged  and  necrotic.  i^:';£,  bLndilljS.rSXr 


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uiiii  sliiiiilviiij,',  Siicli  ;v  ]iror"s,s  I'iiii  I)0  seen  in  tliis  siu-ciincti  of  imii]i'- 
winlitis  fioiii  !in  ox,  in  whii-li  tlicri'  wvk  mnst  oxtrnsive  V(,'j,'i'tiitivf 
ami  desti'iii'tivi'  (.'liaii;,'i's.  Not  uiilVcinn'iitly  tliu  vcfjutatioiis  arc  t,'''itty. 
from  till!  (lc|i()sit  of  lime-salts,  whiili  may  take  placi!  in  voiy  anuto 
oasi'S,  and  is  not  necessarily  an  imlication  ofa^^'e.  It  is  intiiresHiif;  to 
note  how  often  inor^'anie  material  is  tleposited  in  the  neighbourhood 
of  mi(;ro-or;,'anisms,  as  hen:  on  tlie  endocardial  outgrowths,  in  the 
tonsillar  crypts,  and  aliout  tlio  tufts  olactino-myees.  Two  conditions 
must  he  distinguished  from  the  lesions  of  malignant  (niyeotic)  endo- 
carditis :  the  atheromatous  degeneration  in  sclerotic  valves,  uhicli 
loads  to  ulceration  and  extensi\X'  destruction  of  segments,  a  j)roccss 
which  has  notiiing  in  connnon,  e.xcoi>t  in  its  ell'ects  upon  the  valves, 
with  the  acute  ulcerative  changes  above  described,  but  is  similar  to 
the  atheromatous  iirocesses  in  the  aorta.  It  must  not  bo  for- 
gotten, however,  *hat  an  acute  mycotic  jirocess  may  be  engrafted, 
and  indeed,  oftun  is,  ^'.pon  old  sclerotic  valves,  the  seat  of  atheroma- 
tous changes.  The  firm  white  globular  thrombi  of  the  auricular  ap- 
pi'ndices,  and  of  the  interstices  of  the  columme  eariiea'  of  the  ventricles, 
have  sometimes  an  appearance  closely  resembling  endocardial  out- 
growths, and  when  softened  in  the  centre  and  ru]>tured,  the  re- 
semblance may  be  very  close  indeed.  It  is  possible  that  the  gra.inlar 
(/I'bris  of  an  atheromatous  abscess  or  a  softened  thrombus  may  jiosscs.s 
irritating  jiiojierties  when  discliarged  into  the  blood. 

Jlis/.iJiH/iciU  C7(.'rmc'(VA'.— The  study  of  a  small  fresh  endocardial 
vegetation  shows  it  to  bo  made  up  of  cells  derived  from  the  sub- 
endothelial  layer,  round  and  fusiform,  which,  liy  their  iiroliferation, 
have  ]>roduced  a  small  nodular  pnijection  on  the  surface  of  the  endo- 
cardium. Varying  with  the  rajiidity  of  the  growth,  the  mass  will 
jiiesent  the  characters  of  a  soft  granulation-tissue  or  a  tolerably  linn 
lilirous  outgrowth.  Usually,  tiie  round  cells  predominate  ;  but  there 
may  be  many  elongated  sidmlle-formcd  cells,  with  three  or  four  pro- 
c  sse-s.  What  part  the  endothelium  plays  in  this  growth,  lias  not 
been  determined.  Tiny  outgrowths  may  be  seen,  in  which  the  process 
aiipi'ars  to  bo  entirely  subendotholial  ;  but  usually,  before  the  mass 
attains  any  size,  the  smooth  surface  is  lost,  and  there  is  dejiosited 
upon  it  a  cap  of  lilirine  in  tin;  form  of  a  granular,  sometimes  stratilied, 
material,  of  varialde  thickness.  Though  this  re.-embli  s  an  oidinary 
c  lagiihiblo  .'xudation,  it  is  probably  deposited  directly  from  the  blood, 
and  is  of  the  nature  of  a  thrombus.  Upon  ami  in  this  layer  may  bo 
found,  sometimes  in  large  nmubers,  those  reniavkablo  little  bodies 
which  have  long  been  known,  when  collected  together,  ,as  Schiiltze's 
granule-ni  uses,  and  wliich  have  of  late  become  prominent  as  tho 
blood-plat  -  of  ISizzozero  and  tho  hieraatohlasts  o.f  Ilayem.  Occasion- 
ally, they  .ire  very  abundant;  and  I  have  seen  soft  warty  vegetations 
com[)osed  .supclicially)  in  great  i)art  of  them.  As  their  connection 
with  endocardial  ami  endarterial  outgrowths  has  not,  so  far  as  1 
know,  been  referred  to,  I  may  bo  permitted  to  call  attention  to  thiso 
two  drawiii'js,  which  further  illustrate  this  ])oiiit.  The  lirst  repre- 
sents the  aorta  fiMin  an  old  man  dead  of  carcinoma,  in  which,  just 
above  the  bifurcation,  three  irregular  masses  are  shown,  one  nearly  nn 
inch  in  length,  which  projected  fully  a  (piarter  of  an  inch  from  tho 
intima  of  tho  vessel.  They  were  attached  to  atheromatous  idcers, 
were  .soft  greyish-white  in  colour,  and  were  eompo.sed  exclu.sively  of 
the  elements  of  Schuitzo's  granulo-mi'-cs,  with  lihrinc-libiils,  and 
liero  and  there  a  few  white  corpuscles.  The  second  drawing  illus- 
trates a  small  aneurysm  of  tho  aorta,  which  has  perforated  tlio 
(esophagn.s.^  On  the  WiiU  of  the  sac,  tho  artist  has  represented  a 
nutnbor  of  irregular  whitish  lines,  which  were  nariow  elevated  rid"e.s, 
also  made  u|i  microscopically  of  these  small  discoid  elements,  the  con- 
nection of  wliirh  with  librine-formation  has  been  strongly  insisted 
upon  by  liizzozero.     Scatt'ied  in  ami  briwj.Lith   the  fibrinous  txudation 


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occur,  and  may  be  very  abuntlint       &  1 ' "     i^^'"' ¥''°" ''',''^''' 
the  nucro-organisms  stained.     Thev  varv  i  anr,A  ,1  .,1  • '  ^'^''^"'«  '^"'y 

that  i„f„,.  ,„„.  „  ,,,„,,,  ,„„,v;'S"i:s  -  ''™k;'°:i 


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8 

mary  disease.     Uy  culture-experiments  alone  can  we  hope  to  have  the 

(iUustioii  st'ttleil. 

The  following  figiirts  give  an  ii]i]iro.\ini,itefstiniatPof  frequency  with 
which  (liirerent  imits  of  the  heait  are  alleeteil.  The  aortic  andniitial 
valve.s  were  aflected  together  in  41  (■as(.'a,  tlie  aortic  valves  alone  in  53, 
tlie  mitral  alono  in  77,  tlie  tricuspid  in  lil,  the  pulmonary  valves  iu 
15,  and  the  heart-wall  iu  33.  The  riglit  heart  is  rarely  atleeted  aloue; 
this  occurred  in  only  9  iu.stances,  in  5  of  wiiich  tlie  tricuspid,  ami  in 
■\  the  pulmonary,  valves  were  involved.  The  valves  are  most  often 
attacked  along  the  lines  of  closure,  as  in  tlie  simiile  endocarditis  ; 
the  auricular  laces  of  the  mitral  liajis  and  the  ventricular  surfaces  ol 
the  aortic  cusps  sulleriug  most  severely.  Mural  endocarditis  is  mo.st 
often  seen  at  the  upper  jiart  of  the  se|itum  of  the  left  ventricle,  just 
h(dow  the  aortic  ring,  in  which  situation  some  of  the  most  extensive 
and  deep  cardiac  ulcers  ':>ccur,  leading  to  jierforation  of  the  sejitum. 
Next  in  order  is  the  endocardium  of  the  left  auricle  on  the  postero- 
external wall,  as  noted  by  Lepino  {Bull,  dc  la,  Hoc.  dc  Biuhyii;  1869). 

Tae  local  elfects  of  the  ulcerative  changes  are  important.  I'erfora- 
tion  of  a  valvo-segment  is  extremely  common;  sometimes  there  is  a 
clean-cut,  ]m_iiched-out  hole,  with  scarcely  any  irregularity  of  the 
edges  ;  more  freiiuently,  however,  there  arc'great  fungous  vegetations 
wliich  com]iletely  close  and  conceal  the  perforation.  Erosion  of  the 
chordai  tendime  is  frecpu-ntly  nut  with,  and  an  entire  grou])  passing  to 
the  papilla  may  be  dcstroyeil,  the  ends  curled  and  encrusted  with  vege- 
tations. Ulceration  of  the  heart-muscle,  leading  to  perforation  of  the 
septum  or  of  the  wall  of  a  chamber  is  a  much  less  fre(pient  occur- 
rence. I  have  collected  notes  of  eleven  instances  ;  three  of  the  sep- 
tum elose  to  the  aortic  ring.  Ulcers  at  the  aoitic  ring  perforated  the 
lett  auricle  in  three  instances,  i'  ,■  right  auricle  in  one,  and  the  right 
ventricle  in  one.  In  a  rema;  :>,ible  cafo  of  Dr.  Stephen  Mackenzie 
(i'athological  Society's  Transactions,  vol.  xxxiii),  the  left  ventricle 
was  jierforated  by  an  nicer  at  the  apex.  In  a  case  cf  Dr.  Curiiow 
(Lancet,  18S3,  vol.  i),  the  ulceration  extended  between  tlie  coats  of  the 
acuta,  and  then  jierforated  into  the  lumen  of  the  vessel,  and  in  one 
of  the  Montreal  cases  there  was  perforation  of  an  aneurv^ni  of  the  aorta 
by  ulceration,  an  instance  of  extensive  ulcerative  enda;  ..ritis  with  the 
production  of  multiide  aneurysm.s.  Another  coniiiKiii  result  of  ulcera- 
tion is  the  luoduction  of  valvular  aneurysm.  The  anterior  llap  of  the 
mitral  valve  is  most  frequently  atleeted,  'and  then  the  aortic  cusps.  Iu 
the  records  of  the  cases  which  I  have  reviewed,  I  was  suii>rised  not  to  find 
thiscoiiditioii  noted  oftener,  only  in  about  12  jier  cent,  of  the  cases  ; 
but,  in  verv  many  cases,  the  record  of  the  auatcjinical  condition  was 
meagre.  I  shall  not  refer  further  to  this  interesting  pidnt,  as  Dr. 
Legg  lm.s  dealt  with  it  very  fully  in  a  recent  lecture  at  this  College 
(iiiMdshau-e  Lecture,  August,  1882).  I  may  observe,  however,  that  tlie 
atheromatousulceiation  is  also  a  frequent  causeof  aneurysm  of  the  valves. 

It  was  Sir  .Tames  Paget  {Mcdko-Ckirimjicnl  Tmnsiictions,  vol. 
xxvii),  I  think,  who  first  referred  to  the  tVeiiuencv  with  which  sclerotic 
and  malformed  valves  are  attacked  by  acute  disea.se.  Chronic  valvu- 
litis is  met  with  in  a  large  numlier  of  cases  of  malignant  endocarditis. 
The  records  which  I  have  examined  give  only  a  ])crceiitage  of  abiuit 
twenty-live  ;  but  th.e  condition  of  the  valves,  except  as  regards  ulcera- 
tion, was  often  omitted,  and  thus  reiiresents  a  very  much  smaller  ]ier- 
cimtage  than  actually  occurs.  In"  more  than  three-fourths  of  the 
Montreal  cases,  selenitic  changes  were  jiresent  ;  and  Dr.  Goodhart 
found  (Pathological  Society's  Trinisactions,  vol.  xxxiii),  in  a  series  of 
sixty-nine  eases,  that  sixty-one  presented  did  thickening  of  the  valves. 
Ill  very  many  of  the  cases,  the  coiiditiun  of  fusion  of  two  of  the  aortic 
cusps  was  ]iresent.  This  abnormnlity  is  almost,  invariably  accomjianied 
by  .sclerotic  changes,  and  to  the  existence  of  these  is  probably  due  the 
fieiiueucy  with  wlii-h  they  are  attacked  by  ulceration.     In  "stvcutceu 


iiiatouM  iiiitiiio  "     '  °'  '-'""'-  "'  '"'  iithuio- 


I,  i"'.'.'''  'T  '•«;"'i''k't1.1o  instance  of  ul.vial 

^,     .  ,  •  ,    V       '  i"'i'li'iinl  producini' 

■sp.rnnen    wlu.'l,    |    laTo  .lenion.-strate  wu" 


aniiui'ysnis. 


»^--l"™i:i-SiS^^^^^^^^^^ 


and  Was  known  to 

propose  to  del  very  folly  wM,    ,i,„;,'  1  ,       o  c,ll    ,t  ™7i',,,       f    ?' 
.0.0.  .pcrfsl  point.:    Tl'o  ,,,<o,  io»v  1  o  ,11 -uS  i,,1o  'J?  '" 

•nycmbolloproa™,,  <,„s  i„  >vl     f  t  M  ,t,         ','■,"'  ""'""' 

,o.,,tivo, ti,o^. i„ .,,i..i, ti,,.;; :™'l'!r; r ™  ,,:;;;S: S"i: 

and  cases  in  whiuh  sumo  of  the  infants  aro  si,.,„l,>    .    i  ""'"Lts 

-tivo.     It   is   renuukable  ].ow  vSaU:  Xr ^  nX' ^;u,.^''r ■ 
Tliey  may  he  entirely  al.sent  in  well  „uu-ke<l  ma  i-na  t  •■,'  .«      Ti 
are  not  neeessa.ily  assoeinted   vith  snpiJn.ti^!     ^i  Xd'T  a  ^.^ 
considerable  number  of  oases,  tl.ev  nres, ,  t  tlie  ,.1,.,,  r     ^ 

-norrl.a,ie  in.aret.,  but   in  tl.^ /.^umliie'lu     ':;;.•;', ::!:':'';;:^ 

ii'ieroroeci,  in  my  fxperieiie,.,  are  alwavs  iirfs'ent  •  ,  ''.'-"  .''"I'l.""''"^'^; 
iiiav  ex-i^t-    in  tl,.,  ,•„  .   i         -Ji   ''   ".'" '.^^  1'"-^' "t  ,   "ut  tile  niieroeowi 

;;£:3»ai::ESLS^s:\™trs,:;:,,t:;;sio^':i,rs 


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iiistani'os,  to  be  duo  to  tlic  eHect  of  the  iinison,  just  as  in  ntlid-  infcc. 
tious  iliscases  ;  in  others,  thry  are  undoulitcilly'fniliolic,  and  a  ininiiti' 
neurotic  or  .supimrative  centio  can  soinctinics  ho  soon,     hi  tlio  nicm- 
branos  of  the  brain,  I  havo  twice  met  with  extensive  suiicrlicial  extrava- 
sation.  Litten  {C'/tariU  AnnalcH,  ISand  iii,  lierlin)  has  called  attention 
to  tho  fre(iuency  of  retinal  haiuiorrlinf^'es,  particularly  in  the  endocard- 
itis of  puerperal  sepsis.     In  .some  instances,  there   are  innunierablo 
miliary  ab.scesses,  more  particularly  in  tho  licart  and  kidneys.     They 
are  often  associated  with  luvmorrliage,  and  tlio  smaller  ones  look   lik'o 
little  extravasations,  but  the  ]iresenee  of  micrococci  and  suppuration  ran 
be  easily  determined  in  stained  sections.    The  spleen  is  most  often  tho 
.scat  of  infarction,  and  next    in   order    the    kidney.s.     Tho  lungs   are 
usually  all'ected  when  the  endocarditis  is  on  the  right  side,  and  there 
may  bo  suppuration   or  even  extensive   gangrene,  but  even  with  de- 
-Mtructive  lesions  of  the  pulmonary  valves  tliere  may  be  no  suppurative 
infarcts  in  the  lungs,  as  in  a  case  of  Dr.  Church  (ralhological  Society's 
Transactions,  vol.   xxvi).      Or  again,  as  in  a  case  of  Dr.    Jloxon's 
(H>id.,    vol.    xix),  there  may   bo   witli  aortic  valvulitis  suppurative 
infarcts   in  the  lungs,  and   simple  ones   in   the   other  organs.     Tho 
gastro-intestinal  canal  may  present  very  remarkable  changes,  duo  to  the 
presence  of  numerous  infarctions,  from  the  size  of  a  pin's  head  to  that  of 
a  split  pea.    They  are  slightly  elevated,  greyish-yellow  in  colour,  often 
surrounded  by  a  zone  of  deep  congestion  or  extravasation,  and   on 
.section  may  show  a  suppurative  centre.     Micrococci  are  present,  as  in 
other  miliary  abscesses,  and  in  several  instances  I  was  able  to  find 
small  embolic  plugs  in  tho  arteries  of  the  .submucosa.     Tho  abscesses 
may  discharge  and  leave  a  small  ulcerated  surface.     In  the  stomach 
there  may  bo  similar  minute  infarcts,    and   occasionally  larger  ones. 
Carrington  (Lancet,  1884,  vol.  i),  has  described  a  remarkable  case  in 
which  there  was  a  gastric  ulcer,  apparently  duo  to  embolic  process,  in 
•^    case    of    severe    endocarditis  ;     and    JMagill    (Britisu    Medic.\i, 
JOUKNAL,  1884,  vol.  ii),  a  casein  which  the  stomach  was  inten.scly  in- 
flamed, tho  mucous  membrane  at  the  greater  curvature  being  black, 
almost  gangrenous.     The  liver  may  present  minute  abscesses,  and  in 
a  number  of  cases  in  which  there  has  been  jaundice  degeneration  of 
the  cells  has  been  observed  (Schnitzler,    JVkncr  Med.   I'rcsse,    1865). 
The  serous  surfaces  are  often  inflamed,  pleurisy  and  pericarditis  being 
not  uncommon  complications.     The  pericardium  is  most  frequently 
allucted  in  rheumatic  ca.ses,  in  which  endocarditis  and  pericarditis  may 
occur  simultaneousl}'.     riourisy  is  met  with  cliiefly  in  connection  with 
the  traumatic  and  puerperal  cases,  and  also  with  pneumonia,  which, 
as  I  shall  show,   plays  an    important  part    in  tho    hisiory  of  this 
form  of  endocarditis.     The  cerebral  lesions  are  of  the  substance  and 
of  the  membranes.     Embolic  softening,  simple  or  suppurative,   is  ex- 
tremely common,  and  in  very  many  cases  head-.symptoms  supervene, 
and  there  i.s  paralysis  of  one  side  or  tho  other.     There  may  be  a  single 
embolus,  producing  extensive  suppuration  or  red  softening,  or  there 
may  bo  multiple  infarcts  in  various  regions.     The  meningeal  crmpli- 
cation  of  endocarditis  has  not  received  much  attention.     Considering 
the  fre(pxency  with  which  it  has  occurred  in  tho  Jlontreal  cases,  five 
in  -tances  ouv  of  twenty-three,  I  was  quite  prepared  to  find  .such  a'largo 
luimber  a.s  twenty-five  cases  ;  that  is,  somewhat  over  12  per  cent.     In 
tho  majority  of  these  cases,  it  occurred  in  connection  with  pneumonia. 
It  is  almost  ahv.ays  cortical,  but  may  extend  to  the  base  and  involve 
the  nerves,  leading  in  one  case,  which  I  saw  with   Dr.   Ross   at   the 
Jlontreal  Hospital,  to  straliismus,  and  also  to  ulceration  of  the  cornea 
from   involvement  of  the  fifth  nerve.     In   rare  instances  the  siiinal 
meninges  are  involved,  and  the  clinical  picture   may  be  that  of  an 
acute  cerebro-spiiial  meningitis  (WwnoWe,  Bull,   dc  Soc.   d'Anatomu; 
18(4  ;  and  lleinoman,  Med.  Record,  New  York,  1881,  vol.  ii).     Acute 
suppurative  p.irotitis  was  noted  in  three  cases. 


\  >^ 


LECTURE  rr. 


roSrtri^;"i;;°;;;i::!rii;:?  t:iS'''"'  ?i -^--«"ti,  it  is  i,„. 

otiu!)-  .lisias,..  •'  'luu.uiy  ausiiig   m   tho   course  of  some 

endoranlitis/with  n-rfoct   o.        li',  '  tlu,,se  with    .I,ro.uc    valvula  • 

tion  ocrurs  alter  an    nurv  or  in     I'i      '"'"f  ""•     ^^■'"-■'■''  "'«  allk- 

caus.,W.^hhaveo|i/i:?^,;:^^^SS;,-,J-tly  produced  ^ 'the 

syi^pto-uf:^;;  ,;"°i:^  ii^'^tX;  -^^  -^-i^^-f^y  diversity  of 
.sati,sla,.t„ry  clinical  fct  re  '  T  o  In,  rn  '"'^  ''''""''  *°  I"'^'^"^"*  a 
I'ebrile  airccti.m  of  vaVS  int.  „ 'itf  w  t..'^''"''\""''  f  *'"^'^'' of  '^ 
any  acute  fever,  witli  'i' ors  ',  i,'  t  1  T^  "?''"'''^  '"'  ^''^'^ 
etc..  Arising  i.i  the  ecu,"  e  o'f'  e  o  h  d  "eat  1^;.;''""'  ^'^^!'^^''"'' 
an  mteusilication  of  the  fever  ovTlhT  •'  1^  'J"'^  ^"^  ^""I'^y 
pyrexia  is  constant,  b,  v  Wa hie  in  t  «  fn  l'"  I''  ^'''^'''''-  '^^'^ 
likely  than  any  otlier  synu  tZ  ti  i- 1  V  '  •  •  ""''"■'"ty,  an.l  more 
tion  of  strength,  delid  ™'  ^w  atin^  .."ih"'''''^''''^*''*'"'^-  ^'"^^''a- 
stitutional  di^tulbance,  a";  ^Sl^t:^^""''"  '^'g"^  "^  ^'-'-'^'^  -n- 

tic:;;:t:;;;^f':SLrLS°cs  ^-'■^i'''  -^«^=  i-^n,  paipita. 

been  old  valvular  disea^erbut  .?a  "oils  lerS^n'^'r'''';.*''*^'''  ^'' 
lieart-syniptonis  remain  in  the  A,  k  ",nm  ,  I-  \  H""  °*  ^^«°«  the 
condition.'and  giving     o  "n    cation  -or    ^   ^"^^'?  ^^   ^'^-^  g«»"'al 

"'iL^'iSi^^'^"  "^•tected"^;;'it^i',' ^LSr  ''^   ^°  ^^'^^'*'  *^^* 

wl^iu  ^^^:^t::^Sr:^SnS^:^  1-a,  symptoms, 

«pleen  ;  bloody  urine  and  in  i  the  ?/-■"' n"?'^''"'''"*  "f  ^''^ 
"eys  ;  loss  of  vision  fro  n  „•  1  h  mivrt  "  ""T*'""  °^  ^'"^  l^i''" 
various  o,,ans,  or  gangren  ■'Snl  tii^'dSEn^l-lZli'""""  "' 
siSl^r^f^^he'':;  Sr  if;:S?i[^?^7r ^^'ttkt  a  con. 

;;Wat,^d;oi:,!KtdiS'^;:';i;t,/S^ 

UueutlypomtodouUheiact  that  iullanunation  of  uie'Sve,^  mSt 


-.1 


frr  / 


/ 


<i   . 


'}■ 


I 


< 


12 

Icail  to  jnM'iniii.  Tlin  iiivcsti]r;ati.)ii.s  of  Clmivof  niid  Viilpian  (r!,i:,th- 
Mtilini/r  (IrJ'iirh,  ISll-J),  of  \'iirll(iw  {h'rs,n,nii, /!,■  .IUi,nn//,nii/r,i),  of 
.Id-'cuuil  {Xo/liYiiil  JUiliuiinuii-c  ill  M,il,fi,ii\  iti\,  Hl't.  KiulociilditU;, 
aiid  otIiiT.s,  KriitliliiUy  lud  to  tlic  iV((i;,'iiilioii  of  flirsi^  two  ),'ivat  tv|.i,s 
of  tile  lisoast!,  Of  late,  Hti'l  fiiillit  r  .si'iniruticiii  Inis  Imth  \hm\v  ot'  tin 
ciiNoaw.tli  foiitiiivs  i!w:;i.ly  rcsi'iiildiiiK  ii^iiu  or  intciihiUciit,  mid  hImi 
ol  ciiscs  ill  which  thu  ciirdiac  syiii|itoius  iirc  inoNt  |iioiiiiiu!iii  ;  and  I 
shall  call  iitt<'iitioii  to  (•crtaiii  cums  in  wliicli  tiic  .syiniitonis  are  tlio.so 
of  an  aciitu  alluitioii  of  the  ccri:lii(i-.'.|]iiiiil  .synti  mi. 

And  tiist  let  MKMllrcct  your  iiticiiiion  for  a  I'lnv  inonicnts  to  those 
oases  in  which  tho  undocavlitis  is  merely  a  luii-t  of  a  sejitic  <ir  jiya'inic 
state,   tile   result  of  an  external   woiinll,   a   iiiier|ier,il   process,   or  an 
acute  iietiiusis.     Somewhat  over  18  percent,  of  the  cases  I  liavo  ana- 
lysed W( --o  cd' this  nature    the  majority  of  tlieiii   occuirin;,'  in   eonne<'- 
tion  with  innrperal  fciver,  11  jier  cent. ;  ihu  others  in  a.s.soeiation   with 
various   wounds  and   injuries,  or  acute  necrosis  of  bone.     The  ]iuer- 
peral  eases  ii]ipcar  most   fn'(|uent  after  alxirtion,   and   the  lirst  svm- 
litonis  usually  develop   within  a  week  or  ten   day.s  of  delivery,  liei,'in. 
iiiiiK  with  rif^ors  and  fever,  and  running,'  a  eour.se  not  e.ssentially'ilif- 
feieiit  from  ordinar     pucriieral  septicicniia  or  pyieniia  without  endo- 
cardial complication.     Sometime."    the  on.set  of  the  .sym|)toms  may  bo 
mud'   didayed,  and   the  patient  up  and  about  her  duties   when   the 
attack  comes  on.      Usually,  there  is  local  inllammatiou  of  the  uti'rus  or 
ligaments  ;    niembranous-diphtheritic-endometritis,  and  phlebitis,  are 
common.   Oirasionally,  there  may  be  n  )spci'ialallectionof  the  <,'eiierative 
organs,  as  in  a  veiy  severe  case  reported   by  Dr.  Mo.\on   (TatlKdo^deal 
Society's  Transactions,  x-'),  in  which   there  was  extensive  endocard- 
itis of   tlio  rieht   lieart,    i.;id  slou^diing  patches  in   the   lungs.     Tho 
woman  had  been  deliveied  within  the  month,  and  the  utei  is  appeared 
ill  a  state   iiornial   for  tho  jieriod.     Tho   endocardial   lesions  are  not 
iieecssarily  ulcerative,  but  may  be  vegetative,  and  ncca.sioiially  supjiu- 
rativc.      It  is  very  evident,  from  tho  records,  that  valves  with  sclerotic 
changes   are    most    often   allected.       Tho  visceral   lesions  are  a''-.ays 
sup]mrative,  but  do  not  apjicar  to  be  more  numerous  than  in  cr..ses  of 
pueriieral  .sepsis  without  endocanlitis.     The  lieart-syiii]itoms  may  be 
completely  masked  by  the  general  condition,  and  the  attention  may 
be  directed  to  them  only  by  the  occiiiTciice  of  embolism,     in  this  <  on- 
nection,  it  may  be  remarked  that  malignant  endocarditis  may  attack 
pregnant  women,  and  run  a  rajiid  course  leading  to  abortion.     In  two 
ca.ses  of  this  kind,  Litteii  (Vharile  AHiiahn,  liand  iii,  llerlin)  found  no 
dill'erences  in  the  cdinical  features  or  anatomical  condition,  as  regards 
valves  and  metastases,     in  other  instances,  there  i.iay  bo  tho  rigors, 
sweats,  and  irregular   fever,  leading  to  abortion,   without  the   occur- 
reiice  of  any  suppurative  foci,  as  in  a  ca.se  reported  by  (Juyot  (IJiil/cllii 
(k  Soc.  d'AnitlMiiiii',    1S"D).     Dr.  Truenuiii,  of  Maccaii,   New   liruiis- 
wick,  has  also  sent  me  notes  of  a  case  which  developed  duiiii"  i)re<'- 
iiancy.  '  °'     ' 

The  eases  of  ulcerative  ondoearditis  in  traumatic  and  operative 
septicaemia  are  of  a  similar  luiture,  but  do  not  appear  to  occur  so 
freciueiitly  as  in  the  imerperal  condition.  Many  of  tho  cases  occ^ur 
after  very  slight  injuries,  as  jiaring  a  hangnail,  or  a  corn,  a  sloughing 
])ile,  or  the  passage  of  a  sound  throuj_'h  a  stricture,  There  are  usually 
suppurative  infarcts  in  the  lungs  ;  and,  even  with  extensive  ulcerative 
changes  in  tho  left  heart,  the  pyicniic  foci  may  be  all  in  connection 
with  venous  system  and  right  heart.  This  was  well  illustrated  in  tho 
case  of  a  man,  aged  2."i,  who  was  admitted  to  the  JMontreal  General 
Hospital,  May  ;ilst,  with  a  wound  of  the  radial  artery.  Phlebitis 
followed,  aii(l  cellulitis  of  the  arm,  rigors,  septic  pneumonia,  throm- 
bosis of  the  femoral  vein,  and  .syniiitoms  of  pviciuia.  At  the  iiei'ioii.sy, 
there  were  mimerou.sfoci  in  the  lungs,  and  a  suppurating  thrombusin  tho 
Icmoral  vein.    The  mitral  valve  presented,  on  the  ventricular  face  of  tho 


\   H, 


>3 

i\u\rr\iir  scfiiiiiiit,  ,1  j.ati'li,  of  tlio  si/o  of  a  sixiiriiiT,  .swollen  ami  "iwisli 
wiiitM  111  col.iiir,  aiui  opjiositp  to  it,  on  the  auiinilar  face,  was  an  lilnT 
iMj;  (.iioiiirli  to  njiiiaiii  a  small  pea.  Tliwv  was  aiiollicr  also  on  tlio 
wall  III  til,.  l,.|t  aniicln.  TliiMv  wcir  no  iiilairts  in  tlii' arfciial  svstfiu  In 
thcso  cases  ot  i.ii,T|M;ial  ami  tiaiimatic  s..|,ti(a.mia,  tlui  rif,'lit  heart  Ih 
iiioruti(i(|iientlyaire,t.Mltlian  in  aiiv  otiier  poiip  ol'eases.  Thus  ofthe 
thiity-seveii  eases  of  this  kiml,  theiv  weiu  thiiteou  in  whilh  tho 
trieiis|iii|  or  piilmoiiary  valves  were  involvi'il. 

Ill  the  aeiite  iKvn.sjs  of  Imi ir  aiiite  ostoo-myclitis,  a  secondary 

omioearilitis  may  drvelop  ;  ami  in  some  instani.cs  the  eliiiieal  features 
iiiaystroiif,'ly  resemlih'  maliu'iiant  emioi'anlitis,  as  was  well  illustrated 
111  the  ease  of  a  lad,  aj^'ed  10,  who  died  after  an  illness  of  less  than  a 
wueksdiiiation,  eharaeterised  l,y  hij,'h  fuvet,  ri^'ors,  sweats,  etc.  No 
loeal  trouhle  was  eoiii|daiiied  of,  and  at  the  jtnsl  wortrm.  examination 
there  was  ulcerative  endocarditis  of  the  right  side,  and  a  imrulent  focus 
in_  tho  septuin  ;  and  it  was  only  after  most  careful  search  that  the 
jirimary  trouhlo  was  found  in  a  small  spot  of  a'.iile  necrosis  of  tho 
tihia. 

These  forms  do  not  strictly  coino  within  tho  provinco  of  tho  phy- 
sician, but  they  must  he  taken  into  account  in  any  description  of 
malignant  eiidoraiditis.  Thi^  souivo  of  the  poison  is  very  evident  in 
the  external  wound  ;  tho  metritis,  etc.,  and  tho  lesion.s,  are  chiefly  in 
tlie  territory  ol  tlu'  venous  system  and  right  heart. 

In  the  i,y;eniic  group  of  caVes,  the  clinical  features  are  of  a  decided 
)iy:emii'  type,  and  here  the  .source  of  infection  is  at  tho  heart,  and  tiio 
iiictastatK!  lesions  arc  chielly  in  the  territory  of  tho  arterial  sv.stem, 
leiidering  very  applicahle  the  name  of  arterial  iiyaniia  given  by  Dr. 
\\  ilk.s  to  this  class  of  eases.  Wo  may  recognise  two  types  of  tlio 
pyieiiiic  lorni  :  first,  the  ca.ses  in  which  the  .symptoms  resemble  closely 
tho.se  ol^  ordinary  iiyiemia,  with  rigors  at  intervals,  sweats,  and  other 
signs  ol  .septic  iiilection  ;  and,  secomllv,  an  important  group,  in 
wliic.i  intermittent  pyrexia  is  a  striking  feature,  occurring  in  re-'ular 
paroxysms  like  ague,  with  cold,  hot,  and  sweating  stages,  fheso 
(oriiis  may  (Kividoj.  as  iiriin.iry  indcpcmlent  airections,  or  coim.  on  in 
the  course  of  rheumatic  fever,  imeumonia,  etc.  In  our  Montreal 
cases,  thi'V  have  not  been  so  marked  as  tho  typhoid  typo.  Tho  fol- 
lowing case,  with  illustrative  chart,  is  a  fair  example  of  pya'mic  .sym- 
ptoms (hie  toendiicarditis  developing  in  t'le  course  of  imeumonia. 

M.  W.,  aged4:j,  a  well  built  n, an,  w;isn.lmittedunder  Dr.  Koss,  Feb- 
ruary'JOtli,  1880.  lie. served  his  lime  in  th-army  ;  he  had  had  syphilis 
and  had  (|uite  recently  had  .syphilitic  ulcers;  had  also  been  a  hard 
drinker.  In  October  1871',  he  was  in  hospital  with  pneumonia,  and 
liad  severe  cerebral  symptoms.  On  Febrmirv  SSrd,  he  had  a  .severe 
ngor,  follow,  d  by  f,.ver,  cough,  and  pain  in 'the  .side.  On  admis.sion 
I'cbruuy  •2til:;i,  tlu-e  were  signs  of  coiisoliilation  at  tho  left  ba.se.  Oil 
the  -JSth,  he  was  deliiiou.s.  On  Maivli  l.st,  tho  I'lisis  .seemed  to  take 
l>lace  ;  t,'mi>eiatur,!  fVll  to  98',  remained  low  for  three  days  and  ho 
seemed  to  lie  ,h.ing  vi^ry  well.  At  1  I'.M.  on  the  4th,  ho  ha'd  a  severe 
chill,  with  vomiting,  and  tollowed  bv  .sweating.  On  the  .^.th  ho  was 
diihrious;  ho  lia,l  another  seveiv  chill  at  2  P.M.,  in  which  the  tem- 
perature ros.'  to  nearly  \0['.  He  had  live  stools  ;  there  wero  no  iiidi- 
cations  [.oiiiting  to  tho  heart.  On  the  (ith,  the  morning  tem).eraturo 
wis  normal  ;  tho  jKitieiit  was  very  lU'ostrate,  sweate.l  a  great  deal  and 
there  was  low  wamleiing  delirium.  From  the  (ith  to  the  9th,  the  toni- 
perature  ros(!  a  degree  each  evening,  reaching  105.3',  its  highest  point 
liil.so  over  120,  and  feeble.  From  this  time  until  the  Mtli,  ho 
grailually  .sank,  remaining  uncou.scious.  Tho  lung-.symptoins  di,l  not 
oxLcml,  but  rather  improMMl.  The  post  mortem  examination  rcvcaleil 
ext,-nsive  ulcerative  v.  getations  on  the  aortic  valves,  purulent  menin- 


giHs,  and  resol 


vmg  pncumoiiia  of  the  base  ,>f  tho  li'ft  In 


The  attack  iiiiiv  be  ushered 


in  with  a  single 


rigor,  or  more  often  a 


1    .. 

■)  ■ 
■    ) 


14 

sonen  ofchilU;  mid  finiii  thw  outmt  tin y  may  coiiHtitiilr  aiiiiiikcil 
fi'iitiiro,  iind,  witli  tlio  HWciitiiiK,  |>ii'.Htnition,  and  iliarrh.ra,  ^ivi'  a 
soptic  I'liiiractfi-  to  tlio  niHc.  A  light  ,jimiicli;'f  may  (level"!),  uml  ntill 
fiiitlior  intensify  tlio  reseinliliinee.  Scmietinies  tlin  ruse  may  inn  on 
for  a  conple  ol  weeks  wi*'  niaikitd  typhoid  .symptoniH,  and  then 
pyii'mii:  featnre.s  develop— li^jors,  sweats,  ete. 

Hnt  liy  far  the  most  rernarkahlo  cases  of  the  pyirmie  group  arc  thoso 
which  present  a  marked  interndttent  type  ol   jiyrcxia,  simnlating  a 
ipicjtidian  or  tertian  ague.    They  may  occur  without  any  .signs  or  iiidi 
cations  of  iieart-diseaso,  or  the  symptoms  may  develop  in  indiviilinds 
the  sulijects  of  dironic  valvulitis.     The  ea.ses  an!  not  nearly  .so  fre- 
.|uent  a.s  those  of  the  typhoid  type  ;  hut  they  have  been  wiiecially 
.studied   hy  Drs.    W'ilks,    Ih'i.stowc,    and   C'oupland   in   this   country, 
Lancercaux    in    France,    Leyden    and     others    in    (lermany.       The 
paroxysuLs  may  have  the  absolutely  typical  features  of  interndttcnt  ; 
the  chilLs,  Iiot  utago,  and  .swi'ating  succeeding  each  other  with  regu- 
larity ;  ami  in  the  intervals   there  may  be  nn  entire  absence  of  the 
fever.     The  nuotidian  type  is  the  most  comnujii  ;  Ihc  tertian  has  occa- 
sioiially  been  described  ;  and  in   rare  instances  two  paroxysms  luive 
recurred  within  the  twenty-four  hours.     The  cases  7nay  be  much  pro- 
longed,  even  lor  three  or  four  months.     One  of  the  lir.st  references  I 
lind  to  cases  of  this  kiml  is  in  a  foot-note  to  one  of  Dr.  Ormerod's 
Oulstonian   Lectures  {MMiml  Gir.dlc,  IS.'il),  in  which  a  case  of  Dr. 
IJond  of  Cambridge  is  narrated— an  instance  of  chronic  valvular  dis^ 
ease,  with  intennittent  fever  and   diarrlnca,  two  paroxy.sjns  occurrin" 
in  the  <lay.     The  ca.so   lasted   four   months.     In  a  remarkable  case 
(Dr.  Hay)  described  by  Dr.  Wilks  (P.kiti.sii  Micdicai,  Jui-u.val,  IStiS), 
during  a  .six  or  wven  weeks'  illnes.s,  rigor.s  recurred   with   such   regu- 
larity that  a  tertian   ague  was  .suspt    ted  for   a   time,   althoni'h    The 
patient  was  known  to  bo  the  subject  of  hcart-di.sease.     In  some  in- 
stances, the  existence  of  ague  previously  has  render. d  the  condition 
much  more  \m    ling.     In  seveml  of   Lancereaux's   cases  {','azrltr  dc 
Mtikdiic,   18(iJ  ;  Archives  (U:i>  rales;   187:5),  the    jiatients    had   had 
intermittent  fever  a  short  tiiii    before  ;  .so  also  witli  one  of  Leyden's 
cases  {Zcilsrhri/ljih-  A'liii.  M  ,1.,  Hd.  iv,  I'.erlin).    Hut  the  nio.st  extra- 
ordinary  case   of  the   kind    is   recorded   bv  Dr.    liiistowe   (liunisii 
Mkdical  JuiiiNAr.,  1881).     A  patient  had  ague  in  October,  chills  onco 
or  twice  a  day  ;  she  was  ill  for  six  weeks  ;  and,  after  an  interval  of  two  or 
three  weeks,  they  recurred  in  the  second  week  of  December,  and  con- 
tinued until  December  23rd.     She  was  well  for  a  few  days,  and  then 
the  attacks    ■ecurrcd  after  sleejung  in  a  cold  bed,  and  persisted  until 
her  admi.ssion  to  hospital  on  February  12th.     For  the  four  weeks  pie- 
vious  to  entrance,  the  attacks  came  "every  twelve  liours  regularly.     A 
murmur  was  noticed  ;  but  the  history  of  ague  was  so  clear,  and  the 
attacks  so  (diaractenstic,  that  a  suspicion  of  malignant  endocarditis 
was  at  first  not  entertained.     It  was  only  alter  the  failure  of  ipunine 
and  a  variation  in  the  character  of  the  paroxysms,  that  a  diagno.sis 
was   reached.     In  Dr.    Cou]>land's   cases   {Mnl    Timcn  and   (hi-rttr, 
1882,  vol.  i),  the  intermittent  pyrexia  was  also  well  marked.     In  none 
of  our  Montreal  cases  was  the  aguish  type  very   pronounced,  tliough 
in  one  or  two  cases  there  were  regularly  recurring  jjaroxysms  of  chills, 
fevei',  and  sweating  ;   but  the  conditions  under  which  the  attacks  de'- 
velo]ied  rendered  the  clinical  features  more  like  orditiary  pya'iuia.    The 
maioritj  of  the.se  cases  ajipcar  to  arise  independently  of  other  all'ections, 
and  occur  among  wlnt  I  liave  referred  to  as  the  primary  class  of  cases'; 
though,  as  already  mentioned,  sonn'  develop  in  chronic  valvular  dis- 
ea.so,  and  <  'hers  appear  associated  in  some  way  with  ague. 

The  tyjihoid  tyfie  is  by  far  the  most  common,  and  the  maiority  of 
the  e;i^e.s  present  features  which  come  under  this  heading.  The  disease 
may  set  in  with  a  single  rigor  or  a  series  of  chills,  most  frc(|uentlv  the 
Jonuer  ;  ofleu  a  ptiiod  of  maldisi  or  ill  health  has  preceded  the  att.K  k, 


tl 


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'5 

^,',l!fi!'"^"Jm"y'r'""''''"  *•'"  Wnintonis  .luvoloi.   ir  th..  curs.,  nf 
son  .,  rnvvr      Th.-  ,.l,,.,ra,t..rs  of  tl,is  Lnu   an.  iiT.^LM.I,ir   t.  LZZ, 


The  Case  of  M.  W, 
Inn  o'Ti"?  4rM""^^"'ll^  ""^  chief  f,.,,turos  ol  this  form. 

th..  back,  loins,  and  ips  S.i  1  fv  "T'l'^^'""'!  °f  ■^''vere  pains  in 
'■api.l,  tongue  ,,  1  S  .'lia  ...  q,  ''"'''"^''  ''i' I'">'lti«.s.  Pnlso 
ing  fron.  tvi.hoi.l  fcver  N,,  ■  .1  n ;  i  I  '™r  «"l'l'°'^«^l  to  bo  sutler. 
be"obtain.,HX  biU  sKa  be.M.  o  nf  ^''^^7'  '^""^'  "''  r'--'^"""''  '^""''l 
to  the  onset  of  the  atta^'k  O  ,  n?L/  ■  '^^  f"""  '^""''  °''  '^^"'^  '^"^y^  I'^'vious 
perspiration  32  no  e  „ntion  ,?;^^  '°"'  *'""P«''^t"''e  104  ;  pulse  110; 
albumen  in  u  in  .On  h  6  1,'  "n  """;'"'  '  V^  heart-munnwr  ;  no 
turo,  104"  ;  pulse  120  dicrot  o  ■  :  7f  ^^''^^ ''^stk-ss  night.  Tempera- 
passed  18  oLs  o  wine  sS-t  I  lllnn  i  ■;'■  "«*«'.«'  eJ  ;  two  stools.  She 
menses,  whish  began  to  dav^  Woody  which  might  have  been  from  the 
pulseweak.  120  ^re  phat'o^n  54  ./,n'  ™°';"'"K-t'"'P'^»'ature  103.27; 
chest ;  bow'els  and  ^^Z'^^U^^^S  ■  "tooTsT  '''"'t  ?4 
coloured  ;  patient  could  not  be  ronse,!  Tlf^^  '  ''t^f « *^'^''au«nt.  high 
seemed  tender,  which  cause.l  her  r,rvn,,fi  ^^'  and  general  surface 
oir  by  catheter'  contain'^rm.iS  ^17^'^'"",?^^'^^ 
-en.  and  many  granular  casts.      I'upil.^.^;;:^'  fej^fc  °^^^£ 


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j'ij^ht.  SoniQ  rigidity  of  imisples  of  arms,  most  marked  on  the  loft  ; 
increasing  coma,  and  death  at  3.o0  i'. M.  of  tlie  7th,  tlie  sixth  day  of 
\uw  serious  illness.  At  neerojisy,  no  hypertrophy  of  heart ;  mitral 
valves  a  trilhi  thick,  witli  small  superlieiat  losses  of  sul)staiice  on  both 
cnrtnins.  Aortic  valves  normal ;  infarcts  in  spleen.  Numerous  small 
liicmorrhngic  emboli  in  kidneys  and  throughout  the  intestines.  Six  or 
eight  suppurating  infarcts  in  brain,  chiefly  near  longitudinal  fissure 
and  on  median  surfaces.  The  case  is  a  good  exam]ile  of  the  primary 
malignant  endocarditis  occurring  in  a  health}' individual,  and  running 
a  rapid  course,  with  symptoms  of  a  tyi)hoid  character.  The  diarrhoia 
was  not  profuse,  though  the  intestinal  lesions  wore  well  marked. 


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f. 

The  Case  of  Ann  O. 

In  the  following  instance,  occurring  in  connection  with  pneumonia, 
tlie  profuse  diarrhrea  and  severe  nervous  prostration  wore  very  sugges- 
tive of  typhoid  fever. 

J.  H.,  aged  40,  drayman,  a  large  well  built  man,  was  admitted.  May 
j3tli,  with  pneumonia.  He  had  been  a  pretty  healthy  man,  though  he 
had  had  two  jnovious  attacks  of  inilammation  of  the  lungs.  He  had  been 
in  the  habit  of  taking  stimulants.  His  present  illness  began  on  the  11th 
with  the  usual  .signs  of  pneumonia,  for  which  ho  consulted  Dr. 
Blackader.  On  admission,  ho  was  delirious  ;  temperature  lOfi', 
respirations  fiO,  pulse  110,  consolidation  of  lower  two-thirds  of  right 
lung,  with  the  usual  physical  signs  of  hopatisation.  On  the  6th  day, 
the  delirium  was  less  marked  and  the  temperature  had  fallen  to  101.. 'i^ 
()n  tho  9th  day,  the  fever  was  103",  and  the  condition  of  lung  remained 
about  the  same.  On  the  l-2tli  day,  1  .saw  him  with  Dr.  Molson.  The 
dulness  iipi)eared  to  be  diminishing  at  tho  right  base  ;  I  could  detect 
110  murmur  at  either  a)iex  or  base  of  heart.     Tho  condition  of  tho 


17 
pati..),t     rPsomMcl    rlosoly     oti.or    rases   of    pneumonia    in    ^yhu■h 

in  ims  u  stance.     1  he  tongue  was  furred  ;  no  alidoniinal  distension  •  .  n 
spots  ;  diarrlnea  had   eonic  on   in  tl,e  past  few   Xys      s?    K   thi^^ 

(lose  (JO  grains)  of  iiuinine,  at  4  i'.m.  did  not  iH'opt  fl.„  t  Tl  "  !  ^ 
which  at    10    A.M.    wa.s    105  0^      On    9fiH,  ,  ^'''^l''''''''*"™' 

very  „,*,„,  ,ei„[,o,l  constant  »ak1,i„s     TJ  ,„„     ^  ^l^     ,  .k.' 

c;:  'Si  i  rs-.^  fiMiir"  ^£r''-« '  "V  f 

rigor;  temperature  rose  to  105"  and  dcaui  took  ,  1  L  If  ''"  '''!^  ^ 
of  the  11th  just  a  n.onth  from  tit  o2t"?^rdis:as''%'Xl^^ 
had  appeared  on  the  .skin  during  tlie  last  few  day    o    w'  Hfe 

split  peas,  and  ai  .section  present  a  gim-i^h    entil    ^s  Tf  t^^ 

r   a'St    "ilf  ""t-^  -S--ts  f-eri'natu^aMo'ok  ng  oSe  ^T 

S^"r  ;i^"ioTkin?S"o'ri£  ^'^llle^^  "^f  ,°^.  ^'''^^• 
auricular  faces,    .bout  2  formuVifn  ires  fiS  tred^ hatS  tto 

masses.  Two  perfontrnfex  tTbe  She  ou\^Zv^^^^^^  r1"'^' 
the  size  of  a  crow  null      ti,„      "  "^LHtLu  lue  outgiowtlis,  eacli  about 

to  the  corpus  Arantii.  AU  of  tLse  mis  .,//''  '"  ''^""''''  "P 
colour  greyish-yellow,  excep/w£  ^^S  Si.^r'^t  ICTZ  ^ 
the  ones  on  the  anterio- mitral  segment  mwl  on  f  ,         1    •    ^'^''°''.-'^'°*  ! 

less,  and  granular  on   se(tion.     C,W.   1    o^,\''"  ''","'  "";■ 
.oft.     No  ii.l!iction,/Th;f,Z,    „r7.1,        m'O"-:  l™ll' 


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f^roy  ci'iitio.  /a/'-sliiirs.  The  (l('e[)ly  oRoliymotii'  patclir.s  scrii 
externally  loncspoinlcil  with  .sinall  inf.iret.s  sitiuited  in  tho  suh- 
niucous  tissue,  anil  surroumleil  liy  a  zoiio  of  ileeply  liiuniorrhagic 
tissue,  above  whicli  tliB  jfrcy  I'llo  {glandular  layer  could  bo 
distinctly  seen.  The  infarct  itself  was  about  the  size  of  a  si>lit; 
pea,  a  little  elevated,  on  section  decii  red  or  greyish  red,  not  in  any 
instance  purulent,  and  surrounded  by  a  ;!one  of  extravasation  from  1 
to  3  centimetres  in  diameter.  They  were  most  abundant  in  the  ileum, 
about  20  in  number.  Foyer's  glands  were  not  swollen.  The  limrviaa 
pale,  swollen  and  soft,  jlraiii..  Vessels  of  pia  mater  full,  jiarts  at  base 
normal.  Thick  purulent  lymph  beneath  arachnoid,  covering  central 
part  of  fissures  of  Sylvius  on  both  sides,  over  both  frontal  lobes  at 
anterior  i)art,  over  the  left  intrapariotal  fissure  and  on  upper  part  of 
cerebellum,  close  to  great  transverse  fissure.  A  good  deal  of  serosity 
beneath  the  membranes.     No  infarcts  in  substance  of  brain. 

In  some  instances,  tho  clinical  features  are  mixed ;  typhoid  and 
l)yienuc  characters  may  alternate,  iis  in  th3  following  case. 

J.  15.,  aged  33,  admitted  January  7th,  1880,  had  been  a  Jiealthy 
man.  Ten  years  atro,  he  had  a  .severe  attack  of  pneumonia.  On  the 
night  of  January  4th,  he  f(dt  uneasy,  and  did  not  rest  well  ;  got 
feverish,  and  in  the  morning  had  pain  .in  tho  side  and  coagh.  No 
rigor.  Symptoms  continued,  and  he  came  to  hospital  on  7th.  On 
admission,  temperature  was  103",  pulse  128,  and  resi)iritions  40. 
.Signs  of  pneumonia  in  right  lung,  lower  three-fourths.  Characteristic 
expectoration.  During  the  first  week  in  hospital,  nervous  .symptoms 
ap|ieared  ;  he  became  delirious,  and  passed  urine  and  fiices  in  bed  ; 
tongue  dry ;  and  on  tho  9th  and  10th  there  was  troublesome  vomiting. 
The  temperature  was  irregular,  ranging  from  100°  to  104';  the  evening 
record  usually  high,  but  twice  it  waslower  than  the  morning.  Pulse 
120  to  148  ;  respirations  32  to  50.  During  the  second  week,  the  in- 
ten.sity  of  the  symptoms  abated  ;  the  temperature  tept  lower,  not 
once  reaching  101°.  The  nervous  prostration  continted,  with  tremor 
of  whole  body,  and  the  discharges  were  passed  involuitarily.  Tongue 
very  dry.  A  very  disgusting  ftctor  emanated  from  tie  body.  He  lay 
like  a  patient  in  tho  third  week  of  severe  typhoid  fever  ;  took  food 
and  stimulants  well.  On  the  19th,  a  painful  swelling  appeared  in  the 
left  parotid  region,  and  he  began  to  have  chills,  anl  sweated  a  great 
deal  each  d<;y.  No  objective  indications  of  hoart-ti'oublo.  The  lung 
cleared  very" much  in  the  third  week,  but  tho  prostration  continued. 
During  tho  fourth  week,  the  swelling  of  the  parotil  increased,  and  on 
February  Ist  an  abscess  was  opened  in  this  regiin.  On  30th,  there 
were  severe  chills,  wit!i  blueness  of  face  and  the  finger-tips.  Much 
sweating,  of  a  profuse  drenching  character.  He  Jecame  brighter  after 
the  abscess  was  opened,  and  tho  nervous  symjitons  were  le.ss  marked. 
Temin'raturc  ranged  from  98°  to  100°,  rising  wit\  the  chills.  In  the 
lilib  week,  he  remained  in  this  state,  with  bit  little  change,  occa- 
sional chills  and  profuse  sweats,  the  picture  bing  more  like  severe 
1  yiemia.  In  the  sixth  week,  the  prostration  ircreased,  and  he  lay  in 
a  iii^avy  uneonscious  state.  No  chills,  but  niffit  profn.so  sweats.  On 
{''ebruary  loth  and  14th,  the  tenii)eraturo  r(^e  very  liigh,  reaching 
lO,'')",  anil  death  took  place  on  the  lith,  after  anillness  of  forty-two  days. 

Th(!  necropsy  revealed  extensive  mitral  eidocarditis,  as  the  only 
special  lesion.  The  base  of  the  right  lung  was  a  little  tinner  than  the 
left,  but  not  granular  on  section.  Only  oneinfant  was  found,  which 
WIS  in  the  u]iper  i»art  of  the  spleen.  Tin  intestines  were  healthy  ; 
tJKtre  was  no  meningitis.     The  paroti<t  absciss  had  almost  healed. 

Viirdlac  linmp.  —  Under  this  heading  ina'  be  arranged,  as  suggested 
liy  Dr.  Hramwell  [Diseases  of  the  JfedH),  tlnse  eases  in  which  patients, 
tliesubjeets  of  chroiiicvalve-disease,  are  attn'ked  with  febrile  symptoms 
and  evidences  of  avccentinulocarditi.sengrst'ted  upon  tlieold  process.  I 
have  already  reuiarkid  on  the  great  fi'ei(U'ncy  with  which  ulcerative 


— >^..< 


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20 

ihangos  aro  fouml  in  I'oniiPction  witli  .sclorotic  endocarditis.  Many  of 
suuli  cases  present  I'eatnres  of  the  pyuMuie,  ty[dioid,  or  eerobral  types, 
and  may  bo  of  tlie  most  acute  character  ;  but,  in  others,  the  process 
api)ears  nnich  less  intense,  and  the  cause  more  chronic.  In  a  con- 
sithn'able  series  of  cases,  the  history  is  somewhat  as  follows.  The 
patient  has,  perha[is,  aortic  valve-disease,  and  is  under  treatment  for 
failinj^  compensation,  wlien  he  begins  to  have  slight  irregular  fever, 
an  evening  exacerbation  of  two  or  three  degrees,  some  increase  in 
cardiac  pain,  and  a  sense  of  restlessness  and  distress.  Embolic  phe- 
nomena may  develop  ;  a  .sudden  hemiplegia  ;  pain  in  the  region  of  the 
spleen,  and  signs  of  enlargement  of  the  organ  ;  or  there  is  pain  in  the 
back,  with  bloody  urine.  In  other  instances,  peripheral  embolism 
may  take  place,  with  gangrene  of  the  foot  or  hand.  There  may  bo  hebe- 
tude or  a  low  delirium.  Instances  such  as  these  aro  extremely  com- 
mon ;  and  while,  in  some,  the  process  may  be  very  intense,  in  others 
it  is  essentially  chronic,  and  may  last  for  weeks  and  months,  so  that 
the  term  malignant  seems  not  at  all  applicable  to  them  ;  still,  in  a 
large  series  of  cases,  all  gradations  can  bo  seen  between  the  most 
.severe  and  the  milder  forms.  Dr.  Green  {Lancet,  1884,  vol.  i)  referred 
to  a  case  which  lasted  .six  month.s,  and  to  another  in  which,  during 
eighteen  months,  there  were  attacks  of  irregular  fever.  I  have  known 
the  febrile  symptoms  subside  for  weeks,  to  recur  again  with  in- 
creased severity  ;  and  there  aro  cases  which  render  it  probable  that 
the  process  may  subside  entirely.  The  ulcerative  destruction,  in  these 
cases,  may  be  most  extensive  ;  and  I  have  seen  the  aortic  ring  with 
scarcely  a  trace  of  valve-substance  loft.  The  process  in  the  chronic 
cases  is  also  mycotic,  and  it  is  to  be  carefully  distinguished  from  the 
atheromatous  changes.  In  very  many  instances,  there  is  no  history  of 
rheumatic  fever  or  of  other  constitutional  disorder  ;  but  the  endocarditis 
appears  to  attack  the  sclerotic  valves  as  a  primary  process,  and  a  very 
considerable  number  of  the  most  typical  cases  are  of  this  kind.  A 
good  example  was  the  following  case,  in  which  the  disease  attacked 
peformed  and  hardened  valves,  and  the  clinical  symptoms  were  pro- 
longed for  nearly  three  months. 

H.  M.,  aged  38,  was  admitted  September  8th,  under  Dr.  Ross.  Ho 
had  a  good  family  and  personal  history  ;  he  had  always  enjoyed  excel- 
lent hea'th.  A  month  ago  he  had  chilly  feelings,  fever,  and  sweating, 
with  vomiting.  He  ke)it  about  until  ten  days  before  admission,  when 
he  took  to  bcii,  with  pains  at  the  heart,  and  fever.  On  admission, 
there  was  marked  aortic  incompetency;  temperature  100'  Fahr.  ;  he 
seemed  dull  and  heavy.  On  15th,  there  was  iliac  tenderness,  and  some 
diarrho'a.  For  the  next  two  weeks,  he  remained  in  same  state,  tem- 
perature rising  at  times  to  103°  Fahr.  During  the  first  week  of  Octo- 
ber, the  i)rosu'ation  increased,  and  there  was  slight  delirium  at  night ; 
temperature  not  higher  than  102°  Fahr.  On  the  14th,  there  was  an 
cuDtion  of  [letechiiu.  From  this  time,  the  tomj)crature  kept  lower — 
IdO'  to  lol'  Fahr.— the  delirium  and  prostration  increased,  and  death 
took  ]ilace  on  the  23rd.  Two  of  the  aortic  cusps  had  fused,  and  there 
were  old  sclerotic  changes  ;  there  were  re.ont  soft  greyish  vegetations  ; 
the  spleen  jiresented  six  or  eigli'i,  infarcts,  one  suppurative. 

These  are  tho  cases  of  ulcerative  endocarditis  which  present  fewest 
dilHotilties  in  diagnosis.  The  existence  of  tho  chronic  heart-disease  ex- 
cites attention  ;  and  even  if  compensation  has  previously  been  perfect, 
the  ulcerative  process  may  bo  the  very  cause  of  disturbing  the  balance 
and  ]iroducing  marked  symptoms.  In  my  experience,  the  existence  of 
fever  is  invarial)le  when  the  ulcerative  jjrocesses  are  due  to  micro- 
cocci, whereas  most  extensive  destructi\'o  changes  may  occur  in  athero- 
rnaious  disca.se  without  any  elevation  of  temjierature.  It  may  bo  pos- 
sible tliat  the  granular  detritus  discharged  from  atheromatous  foci  on 
the  valves,  or  on  the  aorta,  may  have  irritating  properties;  yet,  in  two 
iiislauccs,   I  have  met  witii  most  exteuaive  atheromatous  ulcers  on 


2r 

W^ais!;!,^';''!'  ''"'r  n'"''  '^':'"'"l"""fitios  of  mateml  „,„st  l.ave 

(/>rtna<    1884    vol   11,  liowi'vur,   lias  ior..nv,    to  a  cas^e  of  ulcoiativp 
^.te,.ms    .„    .,„.U     tlK...    was    no     elevation    of    te-t^S: 

C7m/./W_  6Vo«;,.-A   con.si,l(.ra],le   innnl.ir  of  cases  of   mnli-mant 
end  orarduiH  come  under  ol.servation,  ikmIku.s,   in   hospital.,. rn'r 
or  M,e  h,st  tune,  with  Mnq.tonis  of  cerelMal    o'r  eve      I  e  rH  i      ' 

o";  U'd  „   ;.'    '"  •"  "*  ^''V'^""'''"^'  f 'f  ^'  t''^'    "^^'-^"ts  were  Inoui      to 
.o>pit.  1  uneonscion.s,  and  presented  tlie  appearance  of  profound  eerc- 
iM'al  a  leetum.     One  of  th,.   first  .'ases  1  ,'uw  was  of  tl 'is  k^  tL 

l-auent,  a  woman,  a-'d  'Jl»,  was  admitted  on  O.'tober  2-ind  in  an  u  ! 
.onsco.s  state,  and  no  history  could  he  ohl„ined.     0,7  t'  ■'         si  o 
^T"ir^^r'T''V''''  -"l''--l  "'■  ^-t  pain  in  ije  i, 
deVecte  1       T  f'      '^-^■''''"'"'i^  "'  ■'^'*«'''  apex-pnenmonia  were 

Uaected,  _  Te.  peratnre  up  to  lor.  Ou  the  2r.th,  she  passed  urine 
and  nuces  invo  nntarily.  There  was  stral>isu,us  of  the  ri-dit  eve  an  I 
c-Hnn.encns  nlccation  of  the  left  cornea.   Death  tu.,k  place"     tlu  201 

nX Iva  '^'cvpnennunua,  a  patch  of  endocarditis  on  the 

mitidlvahe,  and  supjiurative  meningitis,  iuvolvini; chiefly  the  cortex 
Another  case,  almost  the  counterpart,  was  admitte.l  last\^.r,  un  l'; 

i  Imfss"  n''when"th"""""°"'  ''''"•  r^'^  '^'"l  '^'S''*-"  h°'"«  ''fte 
a  mission    when   the   necropsy  revealed  apex-pneumonia,   extensive 

endocanhtis,  and  suppurative  meningitis.  '  There  may  be  early  ,u- 
r TnHm  r  ^''•■'""■•"  .Y  "'""t  .""y  "'«»'"Seal  impliLtion,  af  i     a 
im  V  b       i    h  -^  7.'^!ocard.tis  adnutted  June  5th,  1881.     The  patient 
n  an    n  '^  'I'li'ions  or  unconscious  at  the  first  visit  of  the  medical 

W^  a  case  narrated  by  Eberth  (Virchow's  Archiv,  ]5and  Ivii) 

Very  many  o  these  cases  die  within  two  or  three  days  of  a.lmission 
and  the  .p.estion  of  diagnosis  has  usuallv  to  be  sus,,ended  ;  indee  Tn 
looking  over  the  records  of  eleven  instances  in  which  these  cerebra" 
oiSZJ"'"  ''''''  '''"'  ''''''''  '"  '•'^"  ■'  '"-•"  '"l"''!  cours^than 

IIunonr%>»!^'J-''^^^'  .'^'''J  /''•""'  ''"''  '■«>'«l"'o-«I'inal  meningitis, 
llunolle  {Lulktm  de  Sec.  d' Anatomic,  IsrS)  records  a  case  of  a  lad 
who  was  admitted  with  syn.ptoms  at  first  like  those  of  ty,  1  oid  fev 
and  then  of  a  marked  cerebro-spinal  character.  Tln.'e  was  also  a  ,u  ,  ,  ! 
nary  atiecuon  and  endocarditis.  The  patient  lived  five  d^t  Ate 
necropsy,  there  were  suppurative  meningitis  of  th..  brain  ,  nd  cord 
^X^cl^ei""^' ^"^^  extensive^leerativoondocardilS  wSl 

A/.l>.*)^!' v?'/ 'i^'iT'^'!'^"*?'' *' '■?"'"*'''^  byHoineman  (Kew   York 
Medical  Accord,  1881,  u).  A  boy  aged  14,  was  admitted  November  l-Hh. 

eld  Is    nS'  r^'T^y  »";.'"^^1  «»"«'«'l  with  pains  in  back  ami  legs 
r  Zn,.  ',  ^''-  "'  ''P^'"*""'   ^o'"it"'g.  and  constipation  ;   he  wis 

of  St'::;,ft5n4S^'^ '''''''  ■>  *^'"p^^''^"-  '''■'' = --'''-» 

Fi!r:^:!;i^%£i'lS;^:^,5;:™-^.   ^03.4-   evening,  105.6. 
Norember21st.  A  purpuric  eruption  wasnoticed  on  the  chest  thenon 
thefaceandafterwardsonthelegsandanus.  Teniperature  104.V  p  Is 
veryfeeb  e  ;  delirium  ;  l,yperft.sthesia  along  the  spne  ;  no  opisthotonos 

Su  nf  r  '"'^'''*f  •  /"^  '■•  ''■  °f  ^h'«  '^^y^  '^'^^^^^   rop  of  pur.' 
punc  spo  s  came  ou   ;  temperature  106= ;   convulsive  movomints.  ^ 

th«  1..       '  m"'''  "^  ''•"•'  "^'""^^  convulsive  seizure,  and  death.     At 
the  necropsy,  there  was  purulent  exudation  on  the  brain     and  the 
meninges  of  the  spinal  cord  were  congested,   opaque,  anS' inrtame 
There  was  congestion  oflower  lobe  of  the  lungs      There  were  remit 

wall  of  the  loft   vtutnc  ^,    a    sinul!   cavity,  ind-     tive    of  probable 


''li 

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'■  .       1,0.*' 

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22 

abscess  and  destruction  of  ti.ssuo,  J'urulent  serum  was  found  in  the 
pericardium  ;  the  kidneys  presented  .mbolic  abscesses.^ 

Certain  clinical  features  may  bo  specially  referred  to  in  a  few  words. 
The  fever,  as  will  have  been  gathered  from  the  previous  statements,  is 
of  a  very  variable  character.  Irregularity  is  the  prominent  feature  ; 
periods  of  low  may  alternate  with  periods  of  high  temperature,  or  a 
remittent  may  become  an  intermittent.  A  remittent  typo  is  most 
frequently  met  with,  but  the  remissions  do  not  occiir  with  any  regu- 
larity. Occasionally  there  may  be  a  continuous  high  fever,  the  ther- 
mometer not  registering  below  103°  for  a  week  at  a  time.  The  pyicmic 
and  aguish  types  have  been  sulHciently  noted. 

The  occurrence  of  a  rash  has  been  described  by  many  observers, 
and,  in  some  instances,  has  led  to  errors  of  diagnosis.  The  most 
common  form  is  the  hivmorrhagic,  in  tho  form  of  small  petechia',  dis- 
tributed over  the  trunk,  particularly  tho  abdomen,  less  often  in  tho  face 
and  extremities.  They  may  bo  most  abundant  over  the  whole  body, 
and  at  times  are  large  and  present  small  white  centres.  "When  severe 
nervous  symptoms  are  also  present,  the  resemblance  of  the  cases  to 
cerebro-spinal  muninsitis,  or  typhus,  may  be  very  close.  In '  one 
instance,  tho  case  was  thought  to  be  liiemorrhagic  variola  (Duget  and 
Hayem,  Comptcs  rendiis  de  la  Sue.  de  Biologic,  1865).  An  erythe- 
matous rash  lias  also  been  observed. 

In  a  ca.so  of  Dr.  Cayley's  (Lancet,  1884, 1),  there  was  a  mottled  red 
rash  on  the  skin.  Colson  {Bull.  deSoc.  d' Anatomic,  1876)  describes  a 
casein  which  tho  rash  was  erythematous,  and  in  spotsdistinctly  papular. 

The  mental  synqitoms  may  be  of  a  very  varied  character.  15y  far  tho 
most  frecpicnt  conditions  are  low  delirium,  and  a  dull,  semi-conscious, 
apathetic  state.  There  may  be  at  the  outset  active  delirium,  or  even 
maniacal  outbursts.  In  a  case  of  Dr.  llabershoii's  {<!ui/'s  Jlo.yiital 
AV^ioWs,  vol.  xvii), there  was  a  condition  di  scribed  as  mental  eccen- 
tricity. When  there  is  exten.sive  meningitis,  there  is  usually  a  con- 
dition of  deep  coma. 

Sweating  is  a  very  fre(iuent  symptom,  and  is  worthy  of  special 
notice,  Irom  the  peculiarly  drenching  character,  which  is,  as  Dr. 
Henry  Thompson  remarks  (Lancet,  1880),  second  only  to  ague,  and 
usually  far  beyond  the  average  mark  of  phthisis  or  pya-mia. 

The  diarrhcea  is  not  necessarily  dependent  on  any  recognisable 
lesion,  and  may  not  be  very  marked,  even  when  the  infarcts  on  tho 
mucosa  are  most  almndant.  As  noted  in  several  of  the  cases,  it  may 
be  profuse,  and  still  further  add  to  tho  resemblance  which  somo  of  tha 
cases  bear  to  typhoid  fever. 

Jaundice  may  be  present,  but  appears  to  be  a  rare  .symptom.  Cases, 
some  of  which  were  mistaken  for  acute  yellow  atrophy,  are  reported 
by  Sclmitzler  {  Wiener  Med.  Pressc,  1865),  Gubler  (dazeltc  Midiculc, 
1862),  Luys  (Ihid.,  1864),  and  Matticeand  Chalvet  (Ibid.,  1862). 

The  heart-symptoms  may  early  attract  attention,  from  the  com- 
plaints of  pain  and  palpitation  ;  but,  as  a  rule,  they  are  latent,  and  un- 
less looked  for  are  likely  to  bo  overlooked.  In  those  cases  with  chronic 
valve-disease,  there  is  usually  no  difficulty,  but  where  the  affection 
sets  in  with  marked  constitutional  symptoms,  tho  local  trouble  is  very 
apt  not  to  attract  attention.  Even  on  examination,  there  may  be  no 
murmur  present,  with  extensive  vegetations,  or  it  may  bo  variable. 
There  are  many  instances  on  record,  by  careful  observers,  in  which 
the  examination  of  tho  i.^art  was  negative. 

The  course  of  the  disease  presents  many  variations,  well  illustrated 
by  the  records  I  have  given  ;  very  acute  cases  may  run  their  course 
within  the  week,  as  in  the  patient  Ann  0.,  already  referred^to,  while 
in  others  the  duration  may  bo  even  two  or  three  months.  Except  in 
certam  cases  in  which  the  patients  are  the  subjects  of  chronic 
valvulitis,  the  course  is  rarely  prolonged  beyond  four  or  five  weeks. 
Somo  of  the  pyaniic  group,    particularly  those  with  intermittent 


>  r 


J.  1, 


\'; 


23 

jivroxia,  aiipear  very  prolonf!C(],  oven  two  or  tlirco  moiiflis.  Tho  most 
iai>i(lly  fatal  case  is  described  by  Kberth  (Vircliow's  yirc/u'r,  Ikiul  Ivii), 
ill  which  a  man,  who  had  enjoyed  previous  good  liealth,  was  attacked  on 
tlie  evening  of  the  25th,  with' rigors,  foUowed  by  high  fever  and  rapid 
unconsciousness.  The  temperature  tliat  night,  when  seen  by  a 
physician,  was  41°  C,  and  the  case  seemed  like  one  of  typhus  with 
meningitis.  On  the  27th,  he  was  removed  to  the  hospital,  where  he 
died  at  5  r.M.  The  temperature  was  42. 4°  0.  There  were  extensive 
ulcers  in  tlie  aortic  valves,  and  supjmrative  infarcts  in  the  brain.  The 
duration  in  this  ciise  was  scarcely  two  days.  In  a  considerable  number 
■of  instances,  tliu  disease  terminates  within  a  week  or  ten  days. 


[.' ' 


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LECTURE    III. 


Diafpwsls.—fow  discnses  present  greater  difflcultios  in  tlio  wiiy  nf 
diiiKiuwin,  ilifficultit'S  wliich  in  iiiaiiy  ciisf.s  are  jiractirally  insiuniDUiit- 
ablu.  It  is  no  (lisfiiiiii^'Piiient  to  tliu  luiiiiy  Hkilltnl  iiiiysiciaiis  who 
have  put  their  cases  uiioii  record  to  say  tliat,  in  fully  one-half  of 
them,  the  diai^'no.sis  was  niaih^  jiost  xwrl.cm.  In  s)iite,'  too,  of  atilo 
nu'inoirs  in  the  Jo\irnais,  the  disease  has  not  been  niueli  known,  and 
it  is  only  of  late  years  that  the  text-books  have  eontained  eha|itera 
upon  it.  The  protean  character  of  the  niahidy,  the  latency  of  tlio 
cardiac  syni[itoins,  and  the  close  simulation  of  other  disorders,  com- 
bine to  ruiulcr  th'3  di^tection  iieculiarly  dillicult. 

In  the  group  of  cardiac  cases  in  which  the  disease  attacks  a  patient 
the  subject  of  chronic  valvulitis,  the  matter  is  usually  easy  enough. 
The  existence  of  fever  of  an  irregular  type,  and  the  occurrenco  of 
embolism,  generally  sutlico  to  make  the  case  clear.  It  must  be  re- 
membered that  simide  warty  endocarditis  not  unfrecpiently  attacks 
sclerotic  valves,  and  may  be  accompanied  by  slight  fever.  Of  course, 
in  chroiuc  heari-discase,  irregular  pyrexia  may  arise  from  other  causcH 
— local  sujipuration,  cellulitis,  etc. — which  must  be  excluded. 

In  rheumati"  fever,  a  disease  in  whi(  h  the  heart  is  more  systematic- 
ally examined  than  in  any  other,  if  with  the  occurrence  ol  a  murmur 
the  symptoms  become  aggravated,  and  assume  a  ty[dioid  or  (jyiemic 
type,  the  recognition  of  the  complication  should  be  ea.sy.  The  on.set 
of  severe  head-symptoms  in  rheumatism— delirium,  with  high  fever 
and  coma — re<(uires  to  bo  carefully  distinguished.  Fortunately,  the 
simple  endocarditis  common  in  this  disease  rarely,  as  I  shall  have 
occasion  to  show,  [nisses  into  the  grave  form. 

In  pneumonia,  a  prolongation  of  the  course,  with  the  supervention 
of  typhoid  or  septic  symptoms,  should  lead  to  a  very  careful  examina- 
tion of  the  heart. 

The  greatest  dilRculty  is  met  with  in  those  acute  cases  resembling 
the  malignant  forms  of  the  fevers  ;  here  the  atl'ection  may  simulate 
typhoid,  tyiilius,  (-erebro-spinal  meningitis,  or  even  hiemorrhagic  small- 
pox. Even  witli  the  detection  of  a  heart-murmur,  the  judgment  may 
have  tobe  suspended,  and  many  cases  die  with  the  general  symptoms 
of  profound  blood-poisoning,  before  the  development  of  any  special 
features  upon  which  a  diagnosis  could  be  based. 

From  typhoid  fever,  with  which  the  cases  are  most  often  con- 
founded, the  mode  of  onset,  the  pyrexia,  and  the  abdominal  symjitoms 
offer  the  chief  points  for  discrimination.  The  onset  of  severe  endo- 
carditis is  more  abru]it,  not  so  often  preceded  by  a  period  of  failin" 
health  and  progressive  weakness.  In  a  large  ntnnber  of  cases,  cardiac 
pain  or  oppression  and  shortness  of  breath  are  mentioned  as  early 
symptoms.  The  fever  rarely  ])resents,  in  the  early  days  of  the  disease, 
the  regularity  of  typhoid,  and  from  the  outset  may  be  very  high.  A 
suilden  fall  to  the  normtd,  or  even  below,  may  occur  ;  indeed,  ir- 
regular pyrexia  is  one  of  the  most  important  diagnostic  signs.  The 
combination  of  diairhcea,  abdominal  distension,  and  a  rose-coloured 
eruption,  points  strongly  to  typhoid  fever.     The  rash,  when  present,  is 


25 

usually  iietuuhiai,  a  rare  circumstainu  in  tyi.lioi,!  fe^vci.  The  duvoloi, 
nont  under  observation  of  pronounced  nmrnmr.s,  i«r  icula  y  Sa  ,tir 
and  regurgitant  is  most  suggestive  of  maligna,  t  endoca  ditis  n  1 
the  occurroneo  ol  emboli  would  l)o  a  positi\e  eonfir  Zion  KiZ 
rarely  occur  in  typhoid  fever,  while  tluj  are  eomiZ  n  Socan litT^ 
II  '«/f -,^^«V'-'r.  t"  I'ear  in  n  nd  that,  in  many  of  th 'mosT  'Se 
cases    death  may  occur,  as  in  any  of  the  infective   disor.U,rwithout 

Many  ,  t  the  cases  pn'scnt  the  clinical  features  of  iiyremia   a   condi 
in  tlH  vl""^'  "'Tf^  exist    depeiHlent  up.m  the  \  Ic      tiv    les^o  s 
^nfec   nn  .?''  '  ""''  ^""f  "'"  '"'^«"°^'^  "««  ''>'^'"=<^^  ^n  ordinary  Sept  c 
/nEratS''  "  """"''  "■  ^"'"■^"'■«^tion  from  a  primary  endo^cSal 

It  is  interesting  to  note  the  similarity  of  those  cases  of  ncito  or,,!. 

It  seenis  strange  that  difliculties  should  arise  in  the  diagnosis  be 
tween  mnlana  and  malignant  endocarditis,  but   the   rLo  df  of  case,' 
pla.nl;y  show  that  for  weeks  or   mmiths   a  condition   oHnLrmitten? 
pyrexia  may  occur,  simu  ating  every  tviio  of  ,uri7„      Ti.„\>„  "* 

difio'r^'  'r^l^r  "'-'l-'-'. --^  S'l-  iSpanTin/SSco" 
ditiona,  may  fulfil  every  condition   of  a  (luotidian   or   tevtinn   ,-r,t„^ 
mitteiit;  and  the  develop- ,e„t  of  cardiac'sy      to"ns!  w  th  bL 
of  the  pyrexial  type    may  alone  determine  the  natur^  of  the  case     ^ 
Etioloyy  and  J'a//io/,.<jy.-\Vith   a   view   of  obtaining    data    ut,o» 
which  to  base  statements  regarding  the  etiological  rSms  of  mX" 

befbre  stated  37"orM""  ^'"'""  T'  '^''  ^'^™''^'«  °*'  ^09  ca  e  Ts 
beto  e  stated,  37  o  tht^e  occurred  in  connection  with  pviemia  trau- 
mate  or  puerperal.      Doubtless  this  number  could  hav^  been  verv 

One  or  two  general  considerations  may  first  be  mentionp,!  Th^ 
period  of  middle  life  gives  the  greatest'  n  ruber  o  ca  es  ^VoS^ 
children  are  rarely  the  victims  ;  there  were  only  ?hree  «;  fourTn^ 
stances  under  10  years  of  age,  and  not  many  mme  over  50  The 
cases  occurring  in  connection  with  rheumitisiri  ,  le„t«  1  ». 
younger  age  than  the  others  ;  there  S  36  st.te  under  So'velf^ 
ot  age  out  of  51  cases  in  which  this  point  was  nSoned  ^"'' 

mSs  and^rii/Sr  °'  '"""'^^''^  ""^  puerperal).    99  were  in 

Persons  debilitated  by  exposure  or  other  causes     or  ad.lintorl   t„ 
crink,  seem  particularly  liable  to  be  attackedTZunsurii  subjects 
iSkely'tS'arir''""'  '''"^"'^  '""'"'  ^^'^  --Plicationtiucte; 
As  has  been  already  referred  to,  the  existence  of  sclerotic  valvulitis 

"She  rti'e'of  ^"^.-'""'Pl^^  ?- cTron1c\%i^^^^^^^^     ^^''- 
be  allowed      Tn  i/      P"™'"-.V.l"'otopathic  endocarditis  must.  I  think 


''iS 

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f 


;i  six.nlic  lover,  li(.;i(i,iclio,  voiuitiii",  rigors,  pyrexia,  and  ofton  early 
Ucliriiiin  and  unconsciousiuss.  Tho  very  acute  cases  re.semlilu  severe 
typlioul  ortyi.lius  but,  when  more  prolougod,  ti  pyi.'niic  condition  nuiy 
ilevelop.  InaniiMilKT  of  these  raHeslhediseiiso  has  attacke.l  persons  with 
chronic  valve-diseasc,  some  while  under  treat  iient,  others  in  whom 
the  coniiicnsation  was  coniidete  and  thr;  old  l.-sions  only  detected  at 
the  necropsy.  In  f>  instances,  tho  ulcerative  process  attacked  aortic 
valves,  2  ol  v.In,  h  w.^ro  fuse.l,  and  had  undergone  the  fibroid  changes 
always  a_ssoii,ii.  d  with  this  nialtorniation. 

In  l'27ol'  the  cases,  the  endocarditis  was  associated  with  other 
diseases  some  o(  the  most  important  ol  which  we  shall  now  iiroceed 
to  consider.  ' 

Uhnunatism.-  .Since  liouillaud  called  special  attention  to  the  fro- 
quency  ot  cardiac  complications  in  this  disease,  its  iini)ortaiico  in  tho 
etiology   of   endocarditis  has   been   universally  recognised      And   as 
regards  the  simple  form  of  endocarditi.s,    tho  general   statements  'aro 
(jiiito  true,  but,  fortunately,  the  graver  and  fatal  form  is  much  less 
common,  much  less,  I  think,  than  is  usually  sujiposcd.     In  f.3  cases 
there  was  a  history  of  rheumatism,  past  or  present.     I  included  every 
case  111  which  there  had  been  the  record  of  an  attack,  recent  or  rcmott" 
In  only  21  did  the  symptoms  of  severe  endocarditis  arise  during  tho 
progress  of  the  acute  or  sub-acute   disease.      In   29  case.s,  there  wm 
simply  a  history  of  rheumatism,  often  years  before,  and  no  mention  of 
tho  occurrence  ol  joint-troubles  at  the  time  of  tho  development  of  tho 
endocarditis.     Dr.  Ogle  called  attention  to   the  fact   that   ulcerative 
cmlocarditis  occurred  very  often  in  persons  in  whom  no  rheumatic 
history  could  be  traced.     Of  21  cases  which  he  reported,  some  of  which 
wore  m-obably  atheromatous,  in  only  3  was  rheumatism  mentioned 
in  only  J  also  of  tho  Montreal  cases  was  the-,  any  positive  history  of 
rheumatism,  either  before  or  during  the  attacks.     The  following  case 
under  the  care  of  Dr.  Ross,  is  a  good  example  of  tho  mode  of  onset    ' 
15.  M.,  aged  22,  a  healthy  girl  until  three  weeks  before  her  admission 
to  hospital,  on  January  4th.     At  that  time  she  was  attacked   with 
rheumatism  of  the  wrists  and  ankles,  not  very  severe,  and  she  did  not 
receive  any  treatment.     A  week  frem  the  beginning  of  tho  attack,  she 
began  to  have  chills,  two  or  three  a  day,  and  she  became  /everish 
During  tlio  next  week  she  became  worse,  had  occasional  chills,  not  de- 
lirious ;  was  brought  to  hospital  on  the  4tli,  in  a  very  low  state.     On 
^r.%        there  was  delirium  and  incoherence.     Pulse  130  ;  temperature 
100        Double  murmur  up  and  down  sternum;  joint-troubles  not 
evident      On  the  6th,  7th,  and  8th,  she  remained  in  the  same  state,  no 
chills  ;  temperatiire  ranged  from  100^  to  102"^.     On  the  9th,  she  was 
more  i-estless      On   the  11th  a   grey   membrane  was  noticed  on  the 
lauces.     On  the  12th,  the  membrane  in  the  throat  had  extended,  and 
covcre,   the  soft  palate.     Temperature  103°.     On  the  13th  she  died 
suadeiily.      1  lie  necropsy  revealed  a  largo  deep  ulcer  at  the  aortic  rintr 
nearly  destroying  one  segment,  and  iienetrating  deeply  between   the 
auricle  and  the  loft  ventricle.     There  were  small  infarcts  in  tho  brain 
extensive  recent  dqihthoria  of  fauces.  ' 

In  a  larger  luimber  than  in  any  other  group,  sclerotic  valves  wore 
tound,  witu  the  existence  of  which  the  i)ast  rheumatism  could  in 
many  instances  be  connected.  A  primary  rheumatic  endocarditis 
was  recognised  by  Latham,  also  by  Graves  and  Stokes,  and  it  is  quite 
possible  that  some  of  the  cases  which  I  have  grouped  as  protopathic 
represented  instances  of  tho  kind  in  which,  if  life  had  been  proloii:r»d 
loint-troubl.-s  might  have  sui)ervened.  ' 

Cases  of  acute  rheumatism  sometimes  occur  in  which  there 
may  bo  multiple  miliary  abscesses  (Fleischhauer,  Virchow's 
Arc/iiv  Band  Ixxii),  and  a  pyremic  condition  similar  to  tho 
case  just  narrated,  but  without  tho  presence  of  endocarditis.  Micro- 
cocci have  been  found  in  these  abscesses,  and  the  cases  ivsomblo  tliose 


'v> 


27 

raru  iusUti<.!.s  of  idiopathic  |.yH.,nia.  It  is  wnrtl.y  of  obst-rvatinn  that 
a  Hl<.n.e,„i,tiou  wa.  ,nost  t,o.,u«ntly  noted  in  co.m.otion  with  to 
rhm.,„ati.  cases,    Koi.crally  a.,   orythc.na.     I„   a  case  of  Dr.    I  irkc« 

1  d'hlul    'The  o     "'"'7"  "•"'  "^'•;"'  •'  ^^-^'^  ""^-^^-l  on  1,0th  ft- 
a  aiian.s      1  he  orr.isional  presence  of  a  .scarlet  rasli  in  rheumatism 

duuctys  lraimi,ii,ms,  vol.  xu),  has  long  heeu  reco-Miised 

Inchorfla,   with   which   siniple  endoi.arditis  is  so  ol-teii   associated 
tlie  malignant  form  verv  r.irely  .supervnes  associatoa, 

I'nauaonia  a.>i  Houiliaua  pointed  out,  is  not  unfrcquontly  coinrdi- 
cated  with  endocard>ti,s,  hut  the  important  ..art  which'it  plays  h"o 
etiuo^yof  the  .naii^-nant   disease   his  not  Leen  generally  reco-Le 

n  the   cases   I  have   reviewed,   it  stands  at    the  head  of    ho  1st   of 
d  seascs  ,n  whi.  li  secondary  endocarditis  of  a  sever,  nature  develops 
51  instances  Imy.ngheen  noted,  rather  more  than  -T,  pe,   cent,  of  t^^.^ 
total  number  ot  cases.      For  this  1  was  ciuito  prepared  by  our  Montreal 

pneu  noma.  Ul  tlie  occurrence  ot  acute  endocarditis  in  this  disease 
ho  s,  acments  are  son.ewhat  div, ,  e.  Douillaud  thou.'ht  tha  in  4 
h.rd  or  lourth  of  the  cases  in  which  there  was  left-si.  edpneum.n  a 
there  was  „,tl.,nn.„t.o„  of  the  serous  men,hrane.s  of  the  iJart  ("isl 
olle,  in  Ins  classical  work  on  pneumonia,  states,  on  the  contrary,  that 
It  .s  a  rare  comphcU.on,  and  this  would  certainly  appear  to  bo  ho 
conclusion  o  the  Committee  for  Collective  Investi^tio  1  for  in  e 
report  upon  l,Oi,o  cases,  endocarditis  is  onlyoncen^ntioned    'jly  ex 

notes    of     103  necropsies   on   cases   .>f    lobar   pneumonia,    and   tho 
occurrence  ot  acute  endocarditis  is  not,.!  in  16  cases,  over  15  p  r  ce,  i 
Ot  these  cases,  1 1  were  of  th..  mali.^Mmnt  form.     An  analysis  of  these 
s  ...ws  that   in  6,  the  l.ft  hu..'  was  involved  ;  in  5,  the  right  •  ii    4 
he  upper  lobe  was  allected  ;  in   7,  the  lower      In  9  of  the  cases  was 

Tn  nin^'itis.     In  the  54  cases  which   I  have  reviewed,  in  W  the  lune 
atie..t,.,  Was  mentioned,  and  in  2.i  the  atlection  was  on  the    i<d  t  so 
and  only  10  on  the  left  ;  ll.trures  which  are  opposed  to  tho  st  tenent  of 
Bou.l.aud,  that  it  is  „.  left-sided  pneumonia  that  en.locar dial    o    J^^^^ 
cation  most  Irejiuently  supervenes.     In   15  cases,   acute  n  en in,°ih    is 

mtral  V;  .P'l^'^'^'^  ^'^'^'^  ««'"'  •''■'■c  often  involved  than  the 
valves  '"Stances,  there  were   old  sclerotic  changes  in  tho 

The  clinical  features  of  several  cases  in  which  tho  endocarditis  came 
on  during  pn..umonia  have  already  been  -iven      In  n     ,v^  nf  H.!«f 
..  the  girl,  .Nj.  a,    aged   29,    ref^.Te.l    t,?  i"  ihe    e      ,?  l^e^e^'th: 
patients  arc  brought  to  hospital  unco,,.,  iuus,   and  die  w  th      a  few 
days   with  symptoms  of  a  grave  cerebral  .lisorder.     In  ot     rs     here  ,^ 
a  history  of  ordinary  pneumonia,   and  the  case  may  pu  ^10  usu  i 
course  and  .lefervescenco  take  place,  when,  in  a  day  or  .so    f '^r  o 
irregular  type  recurs,  and  typhoid  or  pvicn  ic  symptoms wumU  ■       n,i 
majority  of  the  cases  are  of  this  kind      A-iin    so  ,    init.  ^ '  " 

connection  with  iniunes,  and  the  itiei^^uc,^^  bs^KkLrTi:;:;! 
n.onia  and  endocarditis  unconnected  with  any  sepsis!  Two  of  the 
Jlontrea  cases  were  of  this  kind.  In  three  01  four  cases  tlLowero 
rheuniatic^symptoms  precding  or  accompanying  the  pneumo  "a  Ts  n 

3  of  tlie  patients  had  had  pneunm?:;r  bS^":  i,  "1^      tf  the  S 
attack    and  m  ev«ry  one  of  them  there  was  .a  IWstorv  of  eUb.  r  '"ink 
.«g  iubiu  or  previous  ba.l  health.     In  some  cases,  the  J^nla  h^I 


r  i 


H  1 


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i    l| 
I    ll 

t     it 


3.S 

Vartiiilly  or  ontiivly  ivnoIv.mI  nt  tlif  tiiiin  of  death,  in  others  thnri^  wiw 
ml,  or,  iiioio  rrcijmintly,  j^ii'y  li(i|iiitiMfitioii. 

Tilt'  rt'latioii  ol  the  iiiciiin^'itis  to  tliu  piiLMiiiionia  ami  the  ciKlocaitl- 
iti-s  in  imrtiiiiliirly  intcH'stin^',  Tlio  ociaMiomil  orcurn'iici'  of  this 
connilicatioii  in  muuiiiniiia  has  Imuii  rfffrrcil  to  hy  many  writiis, 
|mitit'ularly(!risoIli\  llii^'urnin  (Zirmsscn's  A'/(,'///„y,„,/,V^  Itanil  xii,  ami 
(Jrocntiflil  (,S7.  Tlnuaa.'i's  //nyiilal  /;,/mrf.^,  lf<78).  In  tlm  loa  la.si'.s,  I 
m.^t  with  it  in  8  instaiins.  in  f)  ol  whii'h  thrro  was  also  ondoiarditis. 
The  t'rfqni'ncy  of  the  ussofiution  of  these  two  lomlitlons  in  pni'ii- 
nionia  is  illustrated  hy  the  lij^ures  already  given  :  of  'J')  instanees  of 
meningitis  in  malii;niint  emio.aiditi.s,  If-  cases  ocemred  in  |.nen- 
rrionia.  In  all  the  s|i(riniens  I  have  examined,  there  were  micrueoc't 
in  the  exudation,  and  in  three  cases  many  of  the  cii|iillaries  and  siniU 
arteries  werelilled  with  them  ;  and  it  seems  natural,  win  re  the  emlo- 
ciirilium  is  involved,  to  attribute  the  dccss  to  endudism  from  the 
valves.  But  the  occurrence  of  an  icntieal  (nrtl.al  meninf,'itis 
without  any  valvulitis  shows  that  it  may  l.o  duo  to  other  causes  tlian 
the  endocarditis.  As  Iluguenin  sufjges'ts,  it  may  he  dejiemlent  upon 
the  presence  in  the  blood  of  infective  luaten.il  derived  from  tiio  inlil- 
trated  lung- tissue. 

In  connection  with  the.so  .secondary  or  con.secutivo  inflaninnitions  in 
pneumonia,  it  is  inteicsting  to  lall  to  mind  the  not  unfrctimMit 
occurrence  of  iiericarditis,  and  of  croupous  inllamniation  of  the 
gastrointcstiiuil  canal.  Dr.  Hristowo  some  years  a;;o  noted  the  fre- 
ipient  comidication  of  croupous  colitis  ;  and,  in  103  nccroiisies,  I  havo 
nut  with  this  complication  in  f.  in.stances;  and  in  one  there  was 
e.xtrnsive  croujious  or  membranous  gastritis. 

iJiphlheriii  is  rarely  complicated  with  endocarditis,  and  I  liavo  only 
been  able  to  find  two  or  three  instances  in  whi(di  severe  symptoms 
were  present  ;  yet,  in  .some  woiks,  endocarditis  is  stated  to  lie  not  an 
uncommon  setiuence.  Labadie-Lagravo  {IShII.  dr  la  Uvc.  </'Aiiii/omie, 
1877)  regards  it  as  such  ;  but  it  is  ].robabIe  that  what  he  <lescribed  as 
vegetations  are  only  Albini's  little  nodules,  the  remnants  of  fotal 
structures.  In  108  necrop.sics  in  diphtheria,  Tolamon  (Pnyres  Mi'di- 
cal,  187!t)  did  not  meet  witli  a  single  case  of  endocarditis  ;  and  my 
experience  has  been  the  same  in  30  pust  mortem  examinations,  many 
of  which  were  in  adults. 

In  di/scntcri/,  a  few  cases  have  occurred.  Litten  {ChariU  Annalcn, 
Band  iii)  has  recorded  an  instance  in  which  there  was  cxten.sivo  ul- 
eeration  of  the  aortic  va'  ■  and  one  of  the  Montreal  ca.ses  occurred 
ill  connection  with  acutt  •  .Ir  !  \ 

In  the  cniptivr  fti-cr.-  gj  .e  endocarditi.s  occasionally  develops— 
m  tyjdioid,  in  scarlet  fov.  i  id  in  variola  ;  but,  in  the  cases  I  liavo 
analyscil,  these  disea.ses  ai)i)ear  of  very  trivial  etiological  signilicanco. 

In  m/Hc,  as_I.anccrcau.x  {Ga;cltcMidicuk  dc  Paris,  1862 ;  and  ArchU-cs 
Gencralis,  1873)  first  pointed  out,  simple  or  severe  endocarditis  may 
develop.  In  sonic  of  these  cases,  as  in  the  remarkable  one  rejiorted 
by  Dr.  Bnstowe,  to  which  I  referred  in  the  second  lecture,  the  parox- 
ysms of  true  intermittent  tever,  and  tlio.se  of  the  ulcerative  endocard- 
itis, .seem  to  run  the  one  into  the  other.'  In  most  of  the  cases,  there 
has  been  only  a  history  of  severe  ague,  and  the  endocarditis  has  fol- 
lowed repeated  attacks.  Dr.  Greenhow  {Pathological  Socicli/s  Transac- 
tions, vol.  XXX)  has  rejiorted  a  very  instructive  case  of  the  kind. 
_  I)r.Goodhart(7'n/;(o%a'rt/;S'yci<?/'srr«)w«t7((m*,vol.xxxiii)niakestlie 
interesting  suggestion  that  ulcerative  endocarditis  is  more  fretiuently  met 
with  at  perimls  in  which  scarlet  lever,  erysipelas,  pyiemia,  and  diphtheria 
prevail.  The  Guy's  Hospital  records  certainly  seem  to  show  that  the 
cases  appear  in  groups  pretty  close  together,  and  at  a  time  when  the 

»  Dr.  Bristowe  informs  me  that,  in  tlie  case  referred  to,  lie  is  incliiio,!  to  reranl 
the  mtennitlent  j.yre.Nia  to  (tei.tii.luiit  lium  the  ouUet  ui.uii  the  cmlecanliUs,  and 
■Ot  Bssiciatcu  with  inalana. 


39 

lIU.'.iSPs    lll(||tin||,,l    ;liv    rpiilitliac,       |,|    MolltliMl,  \W   IkIV.-    Iiail    ocrn- 

siMiiiilly  11  "riin"<.t  I1MI.H  tu^i'thcr;  but   I  Iuivk  not  iictia'il  the  ooii- 
iicctioii  iflcrii'd  to  l)y  Dr.  (Jooillmrt. 

/W/,,;/,,,,//.  -Iai.j.i<m('liii.lis(UNsi(,ii,,ftlioi)iitlii)lo;,7ofnialiKii.iiitciiilo. 
ciinlitis  Willi  .Noiii,.  tivimhitioii,  imitly  <lno  to  a  sciisc  of  iiitoiiiiHtciii'y, 
iiMil  piirtly  lidiii  a  I.tIiiii,'  (Imt  tlif  tiiiii' isHcaicrly  liiic  Tola  satistaitory 
lufsciitatioii  of  til.)  Niilii.,Mt  ;  and  yet  tin  if  aio  m«ns  wliidi  iiiaki- oii'o 
Ivipuliil;  and  It  would  not  hu  rasli  t,,  iMcdict  tliat  tlir  kiiowlcdgo 
twi'iity-livu  yLMirs  hfiiic  will  he  as  luiifli  in  advaiico  of  to-day  is  our 
liiioiination  on  tliu  >iul)itM't  is  of  tli.i  time  when  Dv.  Kirkes  nia.li)  his 
nifinonililu  invcsti^i*:  „.  ,v  sorioun  dilliiMilty  cxi.st.s  in  thoiircuni- 
Htiin.,.  that  wo  liav  •  not  lo  •]  il  with  a  Minulo  form  of  diHoawu— an 
cntiiy— hut  rather  ,ith  a  »[,(■(•  d  innnifeHtation  in  nniny  alhetions  ; 
nlfMaions,  too  tliu  i)a;l!.lo;ry  o(  .vhi.ii  In,  in  most  in.staneo.-i,  hy  no 
nieali.N  elear.  No  oi  .•  ,  i.;  d;.illit  i  ;at  the  more  HeVuru  cases  of  cndo- 
cirdllis  luesont  m  a  ■'.[■uM  nii.e  all  the  features  of  those  diseases 
whieh  we  eall  mleetiv,  ii  (;.iii,ve  to  ho  eaused  hy  the  ahsoriition  of 
some  poison,  till'  deve|o|  ..eiit  of  which  ill  the  l.h  o  1  and  tissues  pro- 
loniidly  ilisturlis,  and  liiially  annihilates,  fun- tioii. 

lirielly  stated,  the  tliuoiy  of  aeiit"  oii.luearditis  which  nt  presiMit 
j.rtivails,  aii.l  the  only  ono  to  which  I  hjiall  refer,  is,  that  it  is  in  all 
Us  lornis,  an  essentially  mycotic  process  ;  tliu  loeal  and  eonstitntioiml 
ollucts  hein«  produced  hy  the  growth  on  the  valves,  and  the  trans- 
teronce  to  disiant  jiarts  of  inieioheM,  whiih  varv  in  character  with  the 
disease  in  whnli  it  develops.  This  very  attractive  theory  can  bo 
iidjusted  to  meet  every  re.|uircinent  of  the  case,  though  as  yet 
lai'king  certain  of  those  suli.-.taiiti:il  data  necessary  for  full  acetit- 
anee,  but  which,  having  been  lurnished  of  late  years  in  other  di^ease3 

we  may  reasonably  hope  will  in  time  also  bo  for'th( ling  for  this. 

Ix't  us  see,  first,  what  has  been  done,  and  how  far  the  facts  at  our 
disposal  seem  favourable  to  this  view.  The  constant  presenco  of 
niicro-oi;;anisms  seems  undoubted;  only,  in  the  siniphi  acute  form,  wo 
nee.  111. .re  careful  observations  with  our  improved  nieth.xls.  Some 
goo.lobseryer.s  have  not  been  able  to  fiml  them  {Otth,  Ichrhuch  der 
.Sp,y iclleu  /at/i„/„,,,,rlie>i  Anatomie,  Lief,  i,  1883)  ;  others  declare  them 
to  be  invariabl..  ciiistituenis  of  the  verrucose  outgrowths  (Klebs,  Airhiu 
far  Krjier  I'aUin/o,//,;  Han.l  iv;  Kiistor,  Virch.nv's  virc/u'y,  Hand  Ixxii). 
Ihe  careful  ai.pli.'atiou  of  such  a  satisfactory  mode  of  .stainin.^  as  le- 
commemled  by  Dramm  should  rea.lily  determine  tliis  question.  A 
study  of  the  en.locarditis  of  puerperal  and  traumatic  pyaemia  will  ho 
m,)st  likely  to  yield  imiiortant  information,  as  here  the  con.litions  are 
simpler,  ami  the  r.dation  ,>f  the  inicr., -organisms  can  more  readily  bo 
determined.  The  cardiac  complication  iu  these  cases  is  only  part  of 
a  general  process,  excited  by  a  local  lesion,  and  is  entirely  secondary 
aiid  subsi.liary.  Micrococci  arranged  in  chaplets  are  constant  con- 
stituents ot  the  \  getations,  and,  iu  tho  case  of  puerperal  fever,  they 
have  a  close  resemblance  to  those  found  in  the  [icritoneal  exu.lation. 
Iho  well  know-n  observations  of  Koch,  Ogston,  and  others  have  shown 
the  relation  of  microbes  to  pya>raia  ;  and  the  recent  culture-experi- 
ments of  Rosenbach  {"  Micro-organisms  bei  den  Wund-Infections," 
AmMcitra  drs  Mnischm,  Wiesba.lon,  lS84)go  far  towar.ls  demonstra- 
ti.m  for  man  what  Koch  ha.l  previously  d.uie  in  tlio  case  of  the  pya'mia 
of  the  mouse  In  these  cases,  a  study  of  the  modes  of  growtirof  tho 
micrococci  of  the  endocarditis,  ami  of  the  ellccts  of  inoculations,  and  a 
comparison  of  those  \<-itli  similar  .)bservati..ns  in  the  organisms  of  tho 
original  lesion,  or  of  the  metastatic  foci,  should  yield  results  of  great 
value  in  the  interpretation  of  the  phenomena  of  secondary  endocard- 
itis. •' 

III  rli.'Uiiiatii' 


fever,  we  are  still  too  far  fiMiuany 
ol  its  intimate  pathology  to   dwell  on   the  nossibl. 


a.'curali'  knowledge 
conue.-'ti.ju  of  any 


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orcraiiism  peculiar  to  it,  and  tho  omlocanlitis  ooinmon  in  its  roiirsp 
K.\ch>i  [Archiv  far  Experiment,  rallwloijir,  IJaiiil  ix)  distinguislics  tho 
muTobos  OMiirnng  111  rlieumatic  cases  from  those  of  tho  septic  forms. 

Ill  iMieuinonia,  micrococci  uiuloubtedly  iiboiiml  in  the  exudation  of 
the  air-cells,  and  tlieir  mode  of  Ki'owtli  in  gelatine  is  peculiar,  but 
the  numerous  experiments  on  artilicial  production  arc  not  yet  conclu- 
sivG.  The  evidence  is  accumulating  wliicli  iilaces  pneumonia  amon" 
the  infective  disorders  ;  and  it  certainly  is  a  seductive  view  to  take  o? 
its  pathology  to  regard  the  local  pulmonary  lesion  as  excited  by  the 
growth  of  micrococci  in  the  air-cells,  and  the  various  consecutive 
iiiMammations,  the  cndo-  and  peri-car.liti.s,  the  pleurisy,  tho  inenin"- 
itis,  the  membranous  gastritis  or  colitis,  as  due  to  the  penetration  Sf 
the  organisms  to  deeper  parts,  and  their  local  development  under  con- 
ditions dependent  on  the  state  of  the  tissues.  The  procesws  are  all  of 
the  character  described  as  croupous,  and  have  as  common  features  the 
presence  of  micrococci  in  a  coagulablo  exudation.  We  have  still, 
however,  to  settle  the  identity  ot  the  organisms  of  the  air-cells  with 
those  of  the  consecutive  iiillaramations  ;  but  we  may  reasonably  hope 
ere  long  to  have  some  positive  data  from  ''nvestigationsin  this  disease 
which,  more  than  any  other,  offers  fa/ourable  opportunities  for  the 
solution  of  these  problems. 

In  diphtheria,  as  we  have  seen,  mycotic  endocarditis  rarely  occurs  • 
and.  111  the  lew  instances  observed  in  association  with  scarlatina' 
variola,  erysipelas,  and  other  affections,  we  lack  positive  information 
with  regard  to  the  characters  of  the  micro-organisms. 

In  the  way  of  experimental  investigation  of  the  properties  of  the 
micrococci,  not  much  has  been  done  of  a  satisfactory  nature  HeibertT 
(Vh-chovi'iArchiv,  Band  Ivi)  placed  bits  of  vegetations  from  a  puerperal 
case  beneath  the  skin  and  in  the  peritoneal  cavity  of  a  rabbit  without 
effect.  Eberth  {Ibid.,  Band  Ivii),  Birch-Hirschfeld  {Archiv  der  IMl- 
kunde,  Band  xvii),  have  produced  panophthalmos  in  the  rabbit  by 
inoculating  the  cornea;  and  I  was  able  to  produce  well  marked  mycotic 
keratitis  in  the  same  animals  with  fresh  material  from  tho  valves  of 
two  cases.  H.  Young,  of  JIanchester,  inoculated  rabbits  with  pus  from 
an  abscess  in  ulcerative  endocarditis,  and  was  able  to  detect  micrococci 
in  the  blood. 

No  conclusive  culture-experiments  have  yet  been  made.  Grancher 
{Journal  dc  Medccinc  dc  Paris,  December  20th,  1884)  has  cultivated  a 
microbe  from  the  blood,  taken  during  life  with  all  necessary  precau- 
tions, but  apparently  not  in  series,  and  no  inoculations  of  animals  were 
made.  Cornil  {L'AiciUa  Medicate,  December  22nd,  1884)  has  made 
cultures  on  golatiue,  but  apparently  no  special  results  have  been 
reached. 

How  •<lo  the  micrococci  reach  the  valves  '?  In  cases  of  ]>uerperal  and 
traumatic  septicajiuia,  the  external  lesion  is  undoubtedly  the  source  of 
inf(CtK,n  which  is  conveyed  through  the  venous  system  ;  and,  in  these 
cases,  it  will  be  remembered  that  the  right  heart  is  most  often 
affected.  In  other  instances,  where  the  skin  is  nnbrokeii,  we  must 
suppose  them  to  gain  access  by  the  lungs  or  intestines,  most  probably 
the  former  ;  and,  m  tlie.se  instances,  ihu  left  heart  is  the  chief  seat  of 
tho  mycosis.  Whether  they  reach  the  valve  with  the  general  blood- 
current  as  Klebs  supposes,  or  through  the  coronary  arteries,  as 
is oster  holds,  cannot  be  considered  settled  ;  but,  from  the  position  of 
the  early  vegetations  in  a  non-vascular  region  of  tho  valves,  and  from 
the  fact  already  referred  to,  that  colonics  of  micrococci  can  be  seen 
directly  upon  the  eirlocardium,  it  seems  probable  that  Klebs's  view 
i.s  the  correct  one.  He  sug-josts,  in  explanation  of  the  fact  that  the 
lines  of  closure  of  the  valves  are  the  usual  seat  of  the  jnocess,  that 
the  micrococci,  circulating  with  tin;  blood,  are  here  closely  pressed 
into  <  'le  endothelium  by  the  firm  apposition  of  the  flaps.  Whether  or 
not  111  any  given  case  endocarditis  will  arise,  dciiciids  "rcatly  on  flie 


.3' 

case  .suUi  as  py  .niia-in  winch  wo  may  sui,p„so  iiiuTobes  ciivu- 
;  n^^  u  the  blood,  t,ho  cudotlu.liun,  of  nonnal  valves  n  ay  o  al  '  > 
ie.i,sl  their  inva.io,,,  or,  even  if  thev  ,lo  lod^e  a.ul  penetmte   the  eo,  - 

afivf  l"i   ^^'  7':'°"«.'^1'«V"^'''^'  ^^■''"•l»  '■^■''t''i--''^  i"  .so.ne  case'      to  uk  r 

m  er     o"to  t  ?k'  H  °"""'  ^^'l'}'"-''-  l-------     Certah,ly  on 

■  ?.   I  ;  r         '  r^'  *''"  T'""'  "■^"'■''  ^  •'"•^■'^  thus  in,i„.rrectlv  and  1  nr- 

o      he  ea,se  fairly  well  ;  but  let  us,  in  eoncdusion,  f.dlow  an  'iniportai  1 
le    00  niueh  neglected,  and  «et  a  definite   outli:      lor  our  i  ',  raS 

m,,uenc,>  of  he  oceurrenee  of  n.ierobes  in  simple  endoearditis  Are 
e..ses?  Secondly,  we  want  full  infoimation  of  the  various  fonn  of 
rt'thrnd':;''""'""^  iyoeondary  endocarditis,  and  ^f  t£  ^la! 
An  tli  dlv  T  '  '''T'i  *,°  ^'^  ^'"^  '-''■'"'°  "f  the  primary  disease. 
M.u'no  .^r  '  '"■'  ""-'y  ""t  *''^  threshold  of  inquiries  relating  to  the 
«  o  V  1  Jit  "'•«^"'^"'/!' to  the  macroscopic'  chara.  ters  ol'  tl 
growtli,   and   to   the   possible   experimeutal  production   of  eiulocar- 

tre!aHd,l°H''"^>  without  thankin.  my  late  colleagues  at  the  Mon- 
treal Geneial  Hospital,  by  whose  kindness  I  have  had  command  not 
only  of  the  pathological,  but  also  much  of  the  dinica  iZt  ri  won 
which  these  lectures  were  based;  and  lastly,  sir,  you  wil  alow  mrto 

or  su(  li  an  intensely  interesting  sub  ect,  and  of  the  distiiHrnisl,,.;? 
audience  which  I  hav.  had  the  honour  of  a.Ulressing       '''''"'""'^'"^'^ 


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NOTES 


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MORBID  ANATOMY  OF  PNEUMONIA. 


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RE-PRINTED  FROM  THE  "CANADA  MEDI    ,L  Sc  SURGICAL  JOURNAL," 

MAY,  1885. 


NOTES  ON  THE  MORBID  ANATOMY  OF 
PNEUMONIA.* 

hvii         ,.,  ^^  WILLIAM  OSLKfi,  UD 

Hoypital,  Montreal. 

Oc„  rl    t  i  *|       Z7  ""'"'°™' """""  ="  "•»  Montreal 
d,„k  fi        'P""  •     ,^»f  ">«  P'TPosea  of  this  article,  I  shall  ex- 

tne  statistical  report  i       -.     Tnmaa  tj^h  j.  ^i 
period  of  ten  .eal^s  was  so.e,v  aT  ™  1^  ^  Z"  ^'^  f^  » 
of  the  deaths  occurring  within  fort^eilt  ho  .s "  ■;Zi:*"''' 
As  a  eonfast,  it  may  be  slated  that  ^he  m„  W  tv  of'  hr 

io'og  a  period  of  twenty  years,  was  only  4,8  ' 

llie  statistical  details  are  as  follows  ■— 

yoal  LaeV  I  ?         1  t  '^''""^  °^'^^"'  ^r>*«  tl^^  tenth 
year  o  cases;  between  loth  and  20th,  6;  from  'zO^h  to  80tl. 

12 ;  between  30th  and  40th,  18  ;  betwee,;  lOtL.d    0  h2    ' 

between  50th  and  60th,  12  ;  and  over  60,  20  cases  '       ' 

1^  bo  h.     As  to  the  position  of  tlic  inflamed  re-non  in  the 
lung  the  hgures  are  :  in  the  right,  whole  organ  solidifi^l  ^^^^^^^^^^ 

th(j  Moutifial  Qonftinl  Ho.pita!  ]  '*  Pathological  Eepn-t  from 

t  Montreal  General  Hospital  Reports.     Vol.  L    Daw«on  Bro.    1880. 


til  in m 


,  it 


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s 

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perhaps,  narrow  margin  at  apex  and  ai'.torior  border)  in  IT  ; 
lower  lobe  alone,  in  18  ;  upper  aloue,  in  7  ;  middle  and  lower, 
in  3  ;  middle  i  id  upper,  in  2 ;  upper  and  lower,  in  3.     In  the 
left  lung,  entire  organ  in  10  ;  lower  lobe  in  Id  ;  upper  lola  in  ♦). 
In  the  cases  oi'  double  pneii'iioni  ■,,  it  wus  most  often  the  lower 
lobcB  which  were  affected  together,  but  in  tiiree  i'lstanctts  the 
lowei'  lobe  of  one  lung  and  the  upper  ol  the  other  were  affected  ; 
in  three  cases  both  upper  lobes  ;  and  in  Cme  XIJX  tho  most  ex- 
tC'^riive  inflar.imation  of  both  lungs  occurred — the  left  was  in  a 
?tat(.!  !.if  uniform  red-hepatization,  with  the  exception  of  the  anterior 
ec-rdcr,  and  the  right  in  the  stage  oi  ,'..;rey-hepatization,  except 
still  smaller  portions  of  the  corresponding  regions.    Altogether, 
in  39  instances  a  lower  lobe  was  invoivcd,  in  19  an  entire  lun^ 
and  in  10  the  upper  lobe. 

Weight  of  lungs. — To  estimate  the  amountof  solid  exudation,  the 
lungs  were  generally  weighed.  The  heaviet^i  was  mCaae  XLVIII, 
a  man  aged  JO,  whose  left  lung,  uniformly  solid,  weighed  2303 
grammes,  and  the  right,  very  congested  and  (edematous,  900 
grammes.  (The  normal  lung  weight  is  between  600  and  700 
grammes.)  In  eight  cases  the  affected  lung  weighed  about  2000 
grammes,  representing  rather  more  than  three  pounds  of  solid 
exudate. 

State  of  lung  tissue  affected. — In  about  one-half  the  cases, 
the  inflamed  area  was  in  a  state  of  red  hepatization.  In  30  per 
cent,  there  were  regions  of  grey  hepatization  with  the  red,  and 
in  22  cases  there  was  grey  hepatization  either  dry  or  passing 
into  the  condition  of  purulent  infiltration. 

State  of  unimolved  portions. — Usually  the  crepitant  parts  of 
the  affected  lung  were  greatly  congested  or  intensely  oedematous. 
The  latter  was  invariably  the  case  when  he  whole  organ,  except 
the  apex  and  anterior  border,  was  involv  hich  then  presented 
a  condition  of  almost  gelatinous  oedem  .  Tiio  unaffected  lung 
waH  2''"erally  congested  and  oeu'  ;  -3,  particularly  at  the 
posterior  part.  It  was  not  unco'  ..i  to  find  the  anterior  por- 
tions (juite  dry  and  bloodless,  whiK  ir.  dependent  regions  were 
full  of  blood  and  serum.  No  doub;,  t'.;'  >,  largely  due  to  post- 
mortem subsidence.  We  do  not  alwayj-  i--'  nxtonsivo  congestion 
or  oedema  in  the  uninflamed  parts.  Thu.^   .  Jcue  XXXII,  in  which 


K?^^ 
^ 


^ 


Ca.«iW/,  a  woman  age.  50  ti  7     ,■"'"■'■     ^°'  »'^°'  '" 

>obe.  the  „ppe..  lobe  'wa"  e^i:  "XTt "' '""  '"°" 

no  redness,  and  no  M„„,|.     .l.|,„  ,.,°  '"''"'"• '"'{  °"  '""''on, 
(except  a  fibroid  onev)  drv  no  J  i  ""'  "'*  """P''""' 

Air  pa>ma„     T      K      ^  "' ""''  ™"'^  "'"o  l'l««'- 

-ro,.  Zd?„  To  .  :,  .  rf"  «°""'^"^  «°"'"=-"  »  <"«.y. 
pneumonle  expeotor  t  !;'"™""  '""""  "'"'™"">™eie  o 

reddened,  ..a^  .:;;:.•  '  ,:X  ■7"^™-  7  .-any 
bronchi  verj,  „fte„  contained  «  f        °"°"'  ""'  '"""er 

stances  thes^o  were  no  ed  n  v  TT  T  """'  ""''  '"  '"«'"»  »- 
the  larger  t„bes  of  t  „  "  /  i'".'"''"';'  "'.'"  «'="''in8  into 
of  the  bronchi  '°«'°"'  '°™'"S  Perfect  casts 

ration.  ^  ^^'     ^"  "°  '"'^^•'^"^e  was  there  suppu- 

The  pleurce. — When  Hio  ;».«„ 

*e  .ung  the  pieura tU'  -t;    r.rdTifhr "-^  ™*-  »f 
"■onljr,  of  a  thin  shcetin..  of  exnd  ^       ■  '  '  '■''™"'  »'"»- 

"'at  it  onl,  produces  turbidity  cftl;  ""    7"  "'  ™°''  '"'"'"""'y 
instances  the  pnen,no„"a  ,  a   d  "'™''™e.     I"  only  two 

pleura;  in  eve'ry  ole;  nraJ!!""'''',"""  ^'^  »»'  ™*  'he 
a  greater  or  less  dc»ree  1,?,,,  """"""r  ™  '■"■'>'™J  '» 
was  extraordinarily"  cu  and  eT  """'  "!°  "^""""^  '"'".'^"' 
".e  Hght  inng  was^nnir:r^;'';„:;^:-^  ^  'Vfj  ^'  '"  "^=* 
every  portion  of  the  pleuri\.«  „  ""-'fe"-  '8  ■»  lbs.  0  ozs.,  and 
layer  an  inch  in  thickness  •  I,  ,e  T  '^  "  """""^  '"•™°- 
exudation,  a^onntin/tHhreo'  T: ^r  '^7  ™  T"' 
was  extensive  donbic   pleuris,  „. " ,  '^  ""  ""*'  "«>« 

"niy-     CW  ^^illustra   dhZ'^l  T™:"  °"  °"'  ^""'^ 
cross  the  anterior  raediastinnl  „    i  '""""mation  could 

left  upper  lobe  to  tUt  of  rr-iX    ''"''  "'''  '"'  ^'»"''  °'' 

wefe:r„\"rsres:::zr,:™STr™'"''^ 

^  o'tuo'efic,  and  tibroid  induration. 


•  .^Penimen  In  the  museum  of  McGill  College^" 


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6 

Abscess.— When  a  lung  in  a  state  of  purulent  infiltration  is 
examined,  wo  wonder  that  softenin;^  and  breaking  down  of  the 
lung  tissue  is  not  a  more  freciuent  result  of  this  i)roces3.    In  four 
instances  there  were  definite  small  abscesses.  In  Case  XXXIV,  a 
woman,  aged  56,  with  grey  hepatization  of  the  right  upper  lobe, 
there  was  a  small  abscess  cavity,  with  shreddy  walls,  the  size  of 
a  walnut,  in  the  anterior  portion  of  the  lobe.  The  tissue  about  it 
was  in  a  state  of  purulent  infiltration.  In  Case XXXVI,  male,  aged 
00,  with  grey  hepatization  of  upper  half  of  left  lung,  there  were 
in  the  central  part  of  the  upper  lobe  several  spots  of  softening, 
the  size  of  marbles,  irregular,  with  ragged,  uneven  walls  and 
purulent  contents.    Case  LXXVII,  female,  aged  64,  with  almost 
uniform  consolidation  of  left  lung,  the  upper  lobe  was  in  a  state  of 
intense  purulent  infiltration,  and  there  were  in  the  middle  portion 
several  large  abscess  cavities  communicating  with  each  other, 
with  ragged  walls  and  purulent  contents. 

Ganyrene. — In  three  instances  this  termination  was  met  with. 
Case  LIV,  a  woman,  aged  J];"),  a  hard  drinker,  was  admitted  with 
pneumonia  of  the  left  lung,  whicii  had  existed  for  some  days, 
during  which  she  had  been  neglected  and  much  exposed  to  the 
cold.     The  lower  lobe  presented  at  its  apoi  and  extreme  base 
signs  of  consolidation,  but  in  the  rest  of  its  extent  was  repre- 
sented by  a  large  gangrenous  cavity,  occupied  by  shreddy  and 
necrotic  lung  tissue  and  blood  clots,  the  whole  forming  a  stinking 
mass.*     The  walls  were  not  defined,  except  at  the  lower  part" 
where  a  separation  between  the  sloughing  and  firmer  lung  tissue 
could  be  plainly  seen.     In  Case  LX,  male,  aged  63,  with  pneu- 
monia of  the  left  lung,  there  was  a  spot  of  gangrene  at  the  apex 
surrounded  by  dark  consolidated  tissue.  Case  LXXIV,  male,  ag<Ml 
r)0,  a  hard  drinker  for  20  years,  admitted  supposed  to  bo  suffeHng 
with  delirium  tremens  ;  had  had  convulsions  before  admissioi" 
Rigidity  of  muscles  of  arms,  coma  and  death  86  hours  after  ad- 
mission.    At  apex  of  right  lung  a  gangrenous  mass  the  size  of 
a  hen's  egg,  surrounded  by  greenish-black  consolidated  tissue. 
Suppurative  meningitis  of  cortex. 


•  Specimen  in  mueseum  of  McGill  Medical  Faculty. 


>■! 


PP' 


caso  „  of  special  intereal,  from  ll.e  fact     12:  "         ""« 

"l<s»™Ho„  almost  from  tl,c  outset  1 1    f       ,   ■"'  "■""""'"■• 
P»tc>,08  a,„l  ,n  a.i  oarl»  ,.,  .        i  'n.li.ralion  «as  in 

laborer,  was  adm  eW.t^lr  ,'"''•'  '"''''''"'  "S""  '^«-  '^ 
ohili  Ave  days  before      llf  ""'  '""»  '"  "■«  *'«•     "ad  a 

100 ;  res,„rat,o„  26.  Expectoration  no  bill  PI  ', '  ° 
of  pneumonia  over  rigbt  lower  mam.uary  iXjl'  "T" 
and  lufra-seapular  rosions      I).,,i...Z    i,     'T  ^-  '"■'''"'''"■ 

patient  made  „o  satisLtZ,  pf„  "^  ''  "T '™  '^>' '"  ''"I""" 
99°  to  10.3»  ;  he  was  heavv  a  .^.  'n  "  "'"™  ""'«"'  '■'■™ 
100  to  120      D,.r,.^H„„  '        '''•'"■'»'"  ■■  pulse  weak, 

ri«>.t  side ;  in '«;  rrr^.ttf-?*''  -^""-  ™ 

absolute  duluess,  feeblo  blovC'l  rca  ,,  r  Tf     '"'1 ''  '""'""'' 
inspiration.     The  nolo  o„       .'»  "™'"nig,  a  few  rules  ou  deep 

cvpcctoration,  muco.,,„rnlenr:  „of  ,    J  '  rtir^irT  'T 
baJ  a  ch,l ,  aud  the  temperature  went  „^p  to  10 1"      N      " 
in  physical  signs.     Died  at  noon  of  the  "7(1,  ,1,     V,       ,         *" 
'J'lio  right  lun..  w,as  nnin„.™l       ,  "         ^  '''^""'  ailmission. 

serous  fluid.     ^ 'r      , '      ""'"™',""  '-«"".  l-atbod  with 

t..-  called  f„r"a"tt:t "'  :';h:"n';:t"rc'  '°"™;'""-^'  f»- 

".0  air-oells  could  be  seen  with      j^'i  :„;;:?:;  "'  '"^ 

Opaque  white  oIn.-,Pf«,.   ,     i        •        '"'""'^s  plugs,  of  a   very 

oils  ted  in  very  s  !  ll^  ■'°'°%'"'^  °''""«''-  '"""  »'»'« 
localized  areas  deelvi'firi'T-  ■  ,  "°"'"^'  "'"■"  ««  '"■'"I 
into  deflnite  ^^l  t t tr  f  T'  """  '?''"«  """ 
of  a  marble.    And  thirdlv    J    *^       ,  "''  ""'  "''°°'  "">  ^^''o 

»'«-M.omo«e„eous:i::z,  ::XuS:f"^ "™; 

connective  tissue.     In  these  arei.  n  fil     -T  V  "^  '''''^"* 

i-l.e  Ions;  the  alveolar  «,;:::"  S,'^^^^^ 

Pini's  fillmg  the  air-cells  were  under^oin,:  ra tXr  '    ,"  ■'7' 
"■  *  giowth  of  connective  tissue.  "■anslo,mat,„„  ,nto  a 


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11  I  :% 


State  of  the  other  Organs — Heart. — Distension  of  the  cliam- 
bors,  particularly  the  right,  with  very  firm,  tenacious  coagula, 
is  a  very  constant  foatuio  *.*  pneumonia  autopsies      The  right 
auricle  is  usually  very  full,  and  a  solid  mould,  capped   usually 
witli  a  huffy  layer,  can  generally  ho  removed  with  the  extension.-; 
into  the  cava  and  many  of  its  branches.     1   have  seen  a  com- 
plete cast  of  the  branches  of  the  superior  cava,  even  to  the 
smaller  vessels,  and  a  mould  of  the  inferior  cava   includin"  the 
he{iatic  and   the  iliac  branches.     From  the  pulmonary  artery 
there  can  be   withdrawn,  by  careful  manipulati"n,  a  dendritic 
clot  representing  the  vessels  of  quite  small  calibre.     In  no  dis- 
ease, I  think,  are  we  likely  to  meet  with  such  solid  coagula— 
so  firm  and  fibrinouf  ;  and  on  several  occasions,  when  I  did  not 
know  the  nature  of  the  case,  the   preliminary  incisions  for  the 
right  chambers  have  ena'led  me  to  make  a  slirewd  guess  as  to 
the  existence  of  pneumonia.     In  many  instances  the  eii'^or"ed 
state  of  the  right  side  and  condition  of  general  venous  stasis 
suggested    the    possibility   that  a    copious   venesection   might 
have  relieved  'Jie  overloaded  chambers — and  I  have  in  several 
cases  acteu  witii  benefit  upon   this  suggestion.     In  extensive 
red  hepatization  th(   circulation  in  the  inflamed  area  must  be 
very  mucl;  impeded,  and  the  w  a-k  of  the  right  ventricle  greatly 
increased.     If  we  may  reason  from  the  experiments  ot  Welch,* 
the  collateral  oedema,  which  wo  have  so  much  dreaded  under 
thei!<;  ciicumstances,  ucis  no  existence  ;  for  he  seems  to  show 
very  clearly  that  to  produce  pulmonary  f-dema  tl)e  hiood  pres- 
sure must  be   raised  t'    .,  point  very  much   bejond   tiiat  whioii 
can  be  induced  '     the  cutting  otFof  certain  territories  of  capil- 
laries, however        'n      ■,  in  a  pneumoi.  ...     Yet  there  are  dilfi- 
cultiL's  in  tlie  w..     tf  e..;  .aining  the  oedema  of  the  sound  portions 
of  the  lung  on  the  view  which  Prof.  We'  'i  holds,  viz,,  that  the 
left  ventricle  is  first  weakened  or  paralyzed  and  the  continued 
action  of  the  right  gradually  produces  the  engorgement  and 
oedema.     It  seems   natural  to  think  that   the  engorged  ri'dit 
ventricle  would  more  quickly  fail  than  the  left,  which  is  rarelv 

•Virchow'a  An;iiiv.  Ixxil. 


9 

Si:,;:'.;;  ;::;;;;"■■•" '-••"- • 

3^1  cases  was  tlio  weight  over   '00   ....  '  ""  ^'^"^™"f     I"  ^n'y 
r>fl«,^/yyi/         <.-«  ^'i-Mmmes— the  heaviest  in 

Cje  LXXV,  was  b .  0  grammes.  In  12  oases  the  woi^ht  was  unrlor 
the  averaire  •  mC^Bo  n/ u  ,    ,.  °       "^  unaer 

n,i     L.      '"'•''  ^'"^  '''«"§«« '"  the  tubules. 

Ojher  Diseases  and  InJuries.~One  case  occurred   in   con 
.;ect.on  wuh  diabetes  and  one  with  erysipelas.     T   .e     c    L" 
ollowed  nyunes,  one  a  burn,  and  one  came  on  a.  the  '0^^  f 

incse  cases  of     contusions-j,neumor,ia,"  as  Litton  terms  this 
form,*  are  very  interesting,  and  may  come  on  aft  r  XL  ' 
«cvere  injuries,  or  after  operations.  °''^  "' 

COMPLICATIONS. 

^^^^^^o^^^^nnsy^y^-au^  pneumonia.     In  one  there  was 

'Zcitschrift  fur  Klin.  Medecin.,  Bd.  V.  ~ 


ll'll 


1  ;■■ 


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If 


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:f  I 


i      ! 


10 


otidocunlitis  as  woll.     Except  in  ('ax''  XClll,  a  portion  of  lun" 
contiguous  to  tlio  iioricanlium  was  involved  in  ouch  case. 

.KndoearJitix. — 1  have  on  several  occasions  called  attention 
to  our  exceptional  cx|  ricnco  in  this  respect,  though,  indoed,  a 
review  of  the  literature  shows  that  the  occurrence  of  this  com- 
plication in  pneumonia  is  by  no  means  infreijuent.  In  l(!  cases 
there  was  endocarditis,  cither  of  the  simple  or  malignant  ty|)es, 
most  often  of  the  latter.  In  five  instances  these  were  simple 
warty  vegetations,  and  there  were  no  special  cardiac  symptoms. 
In  11  cases  the  lesions  were  more  extensive,  usually  of  the  ulcer- 
ative form,  and  the  character  of  the  disease  was  much  altered, 
or  even  masked  by  tliis  com|)lication.  Our  cases  bear  out 
liouillaud's  suggestion  that  endocarditis  most  frequently  compli- 
cates left-Bided  pneumonia,  but  in  a  review  of  30  cases  of  endo- 
carditis occurring  in  this  disease,  and  in  which  the  lung  atiected 
was  mentioned,  I  find  that  in  20  it  was  in  the  right  side  and  only 
10  in  the  left,  so  tliat  it  seems  doubtful  if  contiguity  has  any- 
thing to  do  with  it. 

MeniuyUis. — In  eight  cases  there  was  meningeal  inflammation, 
in  seven  pia-arachnitis,  and  in  one  dura-arachnitis.  In  five  of 
these  cases  there  was  also  ulcerative  endocarditis.  Brief  details 
of  the  cases  may  be  given  : — Case  II,  male,  aged  88  ;  red  he- 
patization of  ujiper  lobe  of  right  lung,  extensive  exudation  at 
base  of  brain,  in  longitudinal  sinus  and  along  the  Sylvian  fissure. 
Case  LXVII,  woman,  aged  G4.  Grey  hepatization  of  left  lung, 
with  small  abscess  cavity  ;  the  under  surface  of  the  duramator 
of  left  hemisphere  covered  by  a  sheeting  of  recent  lymph,  whicli 
could  be  detached  in  Hakes.  No  lymph  beneath  the  arachnoid 
or  at  the  base. 

Case  LXXXIV,  male,  aged  oO.  Grey  hepatization  of  right  uppei' 
lobe  and  a  spot  of  gangrene.  Intense  congestion  of  cortical 
meninges  and  exudation  of  lym{)h  in  patches  over  the  frontal 
and  occipital  lobes  ;  none  at  the  base. 

Tlie  following  cases  were  associated  with  endocarditis  : 
Case  XXV HI,  female,  ag      21).  Upper  half  of  right  lung  liepa- 
tized.    Mitral  ulcerative  endocarditis.    Meningitis  of  the  coitex. 
A  thick  fiake  in  the  neighborhood  of  the  left  fifth  nerve,  and  a'.i- 
other  about  the  optic  chiasm. 


^ 


11 

Cu.e  L,  male,  a^cl  40.     Lower  lol.o  of  ri^I.t  lun;,^     Exten- 
«.vo  cn.locani.t.s  of  ..ufal    u.l  aortic  valvor.     Thi^k  cnial 

Ir  tt  bal  '    "  '"^  ""'"  "'■'^"■'  ''  ""  ''""'^''''^--     ^n« 
(/a«.  Z^V/.V  ,nale,  a^^e.l  43.  Lower  half  of  left  lun^'  affected 
Endocanl,  ,s,  ,n,tral  ar.,1  aortic.     Meningitis  of  tl...  Idt  hlil 
phore   w.tl,  exudation   of  lyni,,I,  over  the   frontal  and  parietal 
convolut.on.s.     None  at  the  ha.se  or  on  the  ri^ht  side 
Case  l^XXXm,ma\o.  Double  pneumonia ;  right  apex.  Ulccr- 

::,:er:^r'""^"'"'*^«'-  ^->-' -in,L.  ^.  ,,m;. 

Vaxr  A7  rx,  fernale,  aged  10.  Red  hepatizatior.  of  central  part 

Menuigitis  of  cortex— both  hemispheres 

The  complication  of  meningitis  is  one  of  the  most  serious  that 

Zrortio'  "'/;""'"^"''''^'  '""^  ''  '''^^'^  "I'f-''^^  i"  ■-  considerable 
cardit        VV       ■  """''^  '"  ---^^-1 -th  ulcerative  endo- 
carditis     We  may  suppose  the  inflammation  of  the  heart  and 
the  menmges  to  be  induced  by  a  common  cause,  or,  what  would 
appear  hkely  m  many  cases,  the  meningitis  is  embolic  i    Ji" 
for  .t  also  occurs  ,n  malignant  endocarditis,  unassociated  w"  h 
pneumoma.     In  :>0  cases  of  meningitis  in  this  disease,  only    5 
ocairred  wUh  pneumonia.     The  infective  material  may  po  slbly 
bo  denved  d.rectly  from  the  inHltrated  lung  tissue,  and  'cried 
off  by  the  pulmormry  veins.     ^Ve  know  tlmt  occa  ionallyl  !« 
omboh  may  be  derived  from  this  source,  as  in  a  case  of^    e^ 
inon,a  occurnng  at  the  General  Hospital  in  1879,  in  w     h 
dunng    1.  progress  o.f  the  disease,  and  not  asso  iated  ^' 
ndocard.t.s,  the.,  wa.  embolism  of  one  femoral  artery    nd 
gangrene  of  the  leg,  necessitating  amputation  above  the  kLe 
Jho  mflammation  in  these  cases  is  almost  always  cortical,  and 
tie  chief  symptoms  are  initial  delirium,  then  stupor  and  coma 
sometimes  rigidity  of  the  muscles.*  ' 

melte  AbhaudlungU  «^<^"^-''""«<^  <"  mimical  material,  Traube's  Uosa- 


M 


m 


;& 


Si    1 
,1 


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12 


I!    ■ 


Croupous  CoUtis.—ln  Cases  TIT,  XXVTII,  XLII,  X.VA'jrT'and 
XC/X  tliis  unusual  complication  was  mot  with.  InCase  III  the 
coecum  was  covered  with  a  thin  layer  of  adherent  Ijmph,  and 
scattered  throughout  the  colon  and  sigmoid  flexure  there  were 
numerous  elevated  patches  of  lymph,  about  the  size  and  shape 
of  rupia-crusts,  which  on  section  were  found  firmly  attached  to 
the  mucosa.  In  this  instance,  the  process  was  very  extensive 
and  the  patches  much  thicker  than  in  any  subscf|uent  case. 
More  often  there  is  a  thin,  Haky  exudation^  involving  only  the 
surface  of  the  mucous  membrane.  In  none  of  the  cases  was 
there  ulceration. 

CroupomGa^trids.—ln  Case  /F,  the  stomach  and  duodenum 
were  found  "  greatly  distended  with  gas.  The  mucosa  was  pale, 
except  about  the  fundus,  where,  just  to  the  left  of  the  cardia,' 
there  was  an  extensive  area  of  croupous  inflammation,  repre- 
sented by  a  thick,  adherent  greyish-white  exudate,  covering  an 
area  12  by  8  cm.  Beneath  the  mucosa  the  membrane  °was 
deeply  injected." 

This  paper  is  meant  to  be  merely  a  statement  of  facts,  a 
record  of  observations,  npon  a  common  and  well-known  diseis'e  • 
but  as  opinion  is  still  divided  as  to  the  <reneral  or  local  nature  of 
pneumonia,  it  is  interesting  to  note  how  strongly  the  evidence 
from  morbid  anatomy  tends  towards  the  former  view.  The 
freiiuency  of  the  occurrence  of  various  consecutive  inflamma- 
tions finds  a  parallel  only  in  some  of  the  specific  fevers. 

While   this  paper  has  but  a  trifling  value  as  a  pathological 
contribution,  to  the   writer,  as  doubtless  to  the  students  °who 
performed  the  autopsies  under  his  direction,  the  careful   study 
and  observation  of  the  cases  upon  which  it  has  been  based  has 
been  of  the  greatest  service.     In  the  investigation  of  disease  a 
knowledge  of  the  morbid  phenomena  observed  during  life  and 
of  the  organic  alterations  found  after  death   are  inseparable. 
The  teaching  of  the  post-mortem  room  must  supplement  and" 
illustrate  the  lessons  of  the  ward,  and,  as  Bichat  says,  it  is 
neither  from  the  one  nor  the  other,  but  from  both,  that  "  la 
veritable  pathologic  "  can  be  gained. 


^TK 


\. 


RK-PlUiVTKI)  FROM  TWI,'  "nA^... 


•(  l^  '-<■  '■!■ 


was 


NOTES  ON  THE  MORBID  ANATOMY  OF 
TYPHOID  FEVER.* 

^'''  WILLIAM  OSLER,  M  D 
UosiiitftJ,  Montreal. 

»way  by  „hL.  ,:;i  ,  isrrz "-' ;°',  ^"'  "-- 

fever,.  The  ^.t:Uu:^^Z^f7  '"'""  "'"'  '^ "" 

"'  '!.«  subject.     L„„..        ,  „  IS  'f  I**"  "'"  '"<"'""  -'i™-'™ 

presented  n  a  manner  n.  l  „,. ,  .""""'^es  ol  eljc  (Ijsoose  were 
ef  enteric  lesions  Zilorf^  "f"'"'""''-  ''''«'  ™>'ta-y 
"'  'I-  disease.     AM  i    ,   rf".'''  """  ."'«  "™« 'W*.</  ,wZ 

«-i.„.:-::t:,^:':t--t: 

•  '«  e.  .h,.  ,.,..,„,„,,.„,  ..pert  .,„„i  Moa.;;^- .7H^,«i, 


'SiC 


1     ! 


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1 


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III 


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,  i 


If  :■ 


i-c 


the  coutinued  fever  of  Great  liritain,  wlicre,  in  reality,  both 
typhus  and  typhoid  existed  to>^cther,  and  the  intestinal  lesions 
were  regarded  as  lecidenta!  occurrences  in  the  course  of  ordi- 
nary typhus.     Meuiiwhilo   Louis'  students,   returnin;^   to  tlicir 
homes  in  different  countries,  had  op[iortunitie8  of  studying  the 
prevalent  fevers  in  the  thorough  and  systematic  manner  of  their 
master.    Among  these  were  certain  young  American  physicians, 
to  one  of  whom,  Gerhard  of  Philadelphia,*  is  due  the  great  honor 
of  having  been  the  first  to  clearly  establish  the  difference  between 
the  two  diseases.      His  papers,  published  in  1887  {Amer.  Jour. 
Med.  iScienoes),  are  undoubtedly  the  first  in  any  language  to 
give  a  full  and  satisfactory  account  of  the  clinical,  pathological 
and  anatomical  distinctions  such  as  we   now  reco'^ni^c.     No 
student  should  fail  to  read  these  articles — among  the  most  classi- 
cal in  American  medical  literature.     Louis'  influence  was  eai-ly 
felt  in  Boston,  to  which,  in  IH:!:},  James  Jackson,  Jr.,  had  re- 
turned, and  in  the  same  year  demonsti'ated  in  his  father's  wards 
at  the  Massachusetts  General  IIos|>ital  the  identity  of  the  com- 
mon tyi)hus  of  the  country  with  the  typhoid  of  Louis,     lie  had 
already  in  18-"j0  noticed  the  intestinal  lesions  in  New  England 
typhus.  Though  cut  off  at  tlie  very  outset  of  his  career,  we  may 
reasonably  attribute  to  the  inspiration  of  the  ycjunger  Jackson  tlu; 
two  elaborate  memoirs  on  typhoid  fever  wliicii,  in  ISoS  and  lS;i!), 
were  issued  from  the  Massachusetts  General  Hospital  l)y  James 
Jackson,  8r.,and  Enoch  Hale.    These,  witli  Gerhard's  articles, 
contributed  to  make  typhoid — as  distnict  from  typhus — widely 
known  to  the  jK'ofession  in  America  long  before  the  distinctions 
were  recognized  in  Enghind.  The  recognition  in  Paris  of  a  fever 
distinct  from  typhoid,  and  without  intestinal   lesions,  way  due 
largely  to  the  infiuence  of  the  able  papers  of  G.  C.  «hattuck  of 
Boston  and  Alfred  Stilld  of  Philadelphia,  which  were  read  before 
the  Societe.  Med.  d'Observation  in  IHoH.     At  Louis'  retpiest 
Shatt'Ack  went  to  the  London  Fever  Hospital  to  study  the  EngHsIi 
disease,  and  quickly  saw  that  there  were  two  distinct  alfeetiuns, 
and  brought  back  a  report  which  must  have  been  very  convincin" 


•  rennock  was  ussociatwl  with  Gerhard  in  his  Mtudies  iipcii  Tyiihtis. 


8 

to  the  members  of  the  Soeietj.     Stills  h-nl   H        , 
gouig  to  Paris  kmnvin.rthoron.rM,,,,-  "  ="^^a»tage  of 

for  he  ha,l  been  Gerht  d's     '   '    "  •'''"■"'^'  ''''^''^^  '^^Vh^s, 
Hospital,  and  had  stud  el  to    ;  J  ^^""r  ''  '''  P^'i'-lolphia 
of  m6.  At  La  Pit  'w  ih  T        f'        ""  ''""  *■"  ^^'«  ^Pi^^'^'^ic 
«on,  while  in  London?  ^.th^  dX  ''"'f.^  ^"'"^^^"^  '^^- 
n>scd  his  old  Philadel-hia  L    ^  L      ''"r'  l^^'^^  ''«  ^eeog- 
woro  given  iu  an  exhaustive  n.n^      T  !'  '^  '"^  «'^'^ervations 
form  the  contrasts  and  di'tin.^;  ^     '  T  ' "^  ^''''''''''^  "'  ^^'^'^'ar 
tweon  typhus  and  t;;^'  tvor'"     '"""'  ^"^  ^"^^^'^^  '- 

*Hri:~::d;;™^^^^^ 

losions   as  only  oecasiori  "  '■'^'''■''•"^'  ^''^  enteric 

-.0,  howeve'  ^S:  L  ^r'^'L  "'  ^^f'''"^"  '^''-o 
always  maintained  that  Jiridit  IT'  ^.  P^-^coptor,  Povell, 
taught  the  differoncos  T  u" e'w  "  '^'f.  '^'  ^"^'  "^'^^  -'' 
t'ui«l.od  Guy's  physician   or   b  ^  r^''''''^  ^"  ^''«   ^^'^^in- 

delineations^f  ^be  .  ^  i^;':^  ^  b'"'"^  ''''''^''^^  ^-^ 
h.^.  Reports  of  Medical  CaLT  v3^  I  t'f"'"^'  '^^'^"^  '" 
article  of  the  first  vohune  of  T  '  '  rr  '  """''  '"  *''''  ^^''^ 
pIeaded,fromthefactsol,.K-,^^'  ""'^''"'  ^^I'^^^s  be 
-^''odinthetreat:^t" 

^••ation  of  irritatin..  ran-.at-  7  '"V^"""""^^''^  '^'^  adminis- 
tinal  disorder;  butli:;;;:^^,;::';:^';;;;^  ^7  up  the  in^^^^ 
'^'^'a  of  two  forms  of  fever  Jo  >,  .  '  '''^'"  ''^"'^  '''"^^^'^t 
J-ions.     lJ,,,bt,  how  V      r        ■''''  '""  ••'''^''-  ^^'^''^'ut  enteric 

»i  treat,,,,.,,!  i„  fevc,_„  „,,„   ,'  ""'V ,"'  "'"  riiiSit,vc  |,la„ 
5  ■i-'i.  /i.   1.  btewart 

Ipiipiiii 


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studied  the  continued  fever.  The  results  of  liis  observations 
were  jjublished  in  1840,  and  his  memoir  has  been  reprinted 
(1884)  by  the  New  Sydenham  Society.  In  the  decade  which 
followed  many  important  works  were  issued  and  the  more  cor- 
rect views  gradually  gained  acceptance,  but  it  was  not  until  the 
publication  of  Jenner's  observations,  1849-50-51,  that  the 
question  was  finally  settled  in  England.  The  Irish  physicians, 
to  whom  wo  owe  so  much  on  the  [lathology  and  trearhiOiit  of 
fever,  were  among  the  last  to  abandon  the  old  views,  and  even 
as  late  as  1801  the  identity  of  the  diseases  was  maintained 
among  them. 

The  extraordinary  difficulty  of  establishing  on  an  incontro- 
vertible basis  any  great  truth  in   medicine,  is  nowhere   better 
illustrated  than  in  the  history  of  the  subject  which   I  have  out- 
lined in  this  imperfect    and    sketchy  manner.      Too  often  a 
truth  has  to  grow   to  acknowledgment   with    the    genei'ation 
which  announced  it.     After   the   intellectual    climacteric— Zti 
crist'.  de  qaarante  am — wo  assimilate   new  truths  slowly,*  and 
some  by  training  become  incapable  of  their  reception.     This 
was  the  case  with   many  an  ardent  student  of  Fever,  whose 
cducatioi)  had  unfitted  him  to  see   a  truth  which  the  untram- 
melled mind  readily  grasped.      Dwelling  now  in    the   clearer 
light  and  with  fuller  knowledge  and   looking  back  o'-or  the  half 
century  of  doubt,  dispute  and  discus.iioi)  upon  ^he  (|uestion  we 
have  just 'considered,  what  lesson  may  we   learn?     Surely  to 
see  in  it  a  picture  of  our  own  times — a  picture  the  counterpart 
of  which  we  can  find  any  day  in  our  current  journals.     The 
mists  of  doubt  hang  over  many  problems,  disputes  rage  with 
the  old  intensity,  discussion  wa.xes  hot,  but  by  the   light  of  his- 
tory wo  can  read  with  faith  and  trust  the  larger  hope — in  no 
faint  manner — that  a  similar  hap[)y  solution  awaits  many  of  the 
(juestions  in  pathology  which  to-day  ve.x  the  mind  of  the  profession. 
Of  the  workers  who  were  actively  engaged  in  defining  the 
distinctions  between  typhus  and  typhoid  fevers  three  only,  so 
far  as  I  know,  remain  with   us— Shattuck   of  Boston,  Still(;  of 
Philadelphia  and  Jenner  of  London.     They,  with  their  fellow- 
*  True  to-day  as  iu  the  timo  of  Harvey. 


(ieepeu.  ^'^"  "°^  «ttacc   but  will  rather 

*  *  *  * 

»ve.a,  occasion,,  e.ooode,!    ^  '„      ?  ?  "7''-  ''-'  »» 
en.lmg  May  lat  1x7.,  .„,,•,  ''""""".y.     For  the  te„  „ea.s 

rate  was  a  Httlo^vo;  iC  r  ^r^'"'"^'"^"^'  ^'^^  ^^^'^ 
8ies,  which  are  arranged  i,.   tlh'u     r  "'*''  "^'  ^'^  ^"^op- 

article.  "      '"  *''^"''^'"  ^^^-^  at  the  end   of  the 

Thirty-six  of  the  cases  were  in  males  and  17  •    p 
Dr.  James  Bell's  statistical  renortT     '  '"  ^''"'^'^-     ^' 

are  admitted  to  the  hospita  w  ' ,  '"'^  '"^"^  '"«'•«  ^^n 

t'^e-"  is  sh-ghtlyloweXniH        "''"''"  ^'^^^-'-^^^  ^-^ou^ 
.1  o     J'  '""I'l  man  ui  tne  wompn      /ic  i-  .  " 

t'le  age  was  given,  20  occurrod  J  ^^'^'  '"  ^^'^'^I* 

^^^^_  occurred  m  persons  under  25  years  of 

In  10  cases  there  w.-e  no  special  complications. 

theie  had  been  hjemorrha-e  from  H,«  i        , 

^'--    were   diphtheritic  tffetL'or' 
membranes.  '^'^'^ct.ons    of   mucous 

there  was  thrombosis  of  veins 
pyaemia. 

affections  of  the  rpqr,;>.nf-> 

lut  respu-atory  organs. 

Anatomical  LEsroivq     w„   i,  n 
cl'ieflj-  occur,  '         "°''  "'"  'P^iS"  ""-Ai.l  chanj-c, 

Germany  ulcers   in       J  ^''"  ^'^^^'  ^^^  «ases.      I„ 

common^  the  :  ly'Ltn.? "^  "^"   ^^   ^^^  -«^^    -' 
-<1  Vienna  post-mor  e.    o  Is      2T  ^""  ^"   ^'^^  ^^-•"» 
'■are  in  England.     Necroiro f  h!  "  '''^'''  ''  '^''^  ^^ 

thyroid  which  were    ou"  Jun  bf   '""?  ''  '''  ^^*  «^"  ^f- 
;:"«:^"i  "P  ^^  ^  convalescent  from  typhoid, 


"  11 

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and  I  have  recently  had  a  patient  with  acute  perichronditis 
which  fortunately  terminated  in  reaohition. 

There  were  no  special  alterations  noted  in  oaHophaym  or  sto- 
mach. The  lesions  of  the  intestines  wore  all  distinctive.  The 
atYection  of  Peycr's  glands  may  he  considered  under  the  four 
stages  recognized  by  all  writers  : 

IstStaok.  8wclUn(j  and  Il/jperphisia. — No  matter  at  which 
period  of  the  disease  a  patient  dies,  some  of  the  patches  will  be 
found  in  this  condition.  It  is  rare,  however,  for  death  to  take  place 
before  necrosis  or  sloughing  has  occurred.  In  Oase  XVII.,  a, 
jdrl,  agivl  24,  died  al)()ut  the  end  of  the  first  week  with  severe 
nerv(jus  symptoms.  The  patches  of  Peyer  were  much  swollen, 
pitted  and  cribrilorm,  lint  no  sloughing  had  taken  place.  Oase 
XXXIL,  a  man  aged  (io  ;  there  was  great  hyperplasia  of  the 
glands,  particularly  ol  the  isolated  follicles,  but  neither  necrosis 
nor  ulceration.  The  usual  condition  met  with  is  sloughing  or 
ulceration  of  the  lower  |)atches  and  swelling  of  the  upper  ones. 
In  the  early  inv<jlvement  one  can  frecjuently  see  with  the 
unaided  eye,  or,  bettor,  with  the  assistance  of  a  lens,  the 
enlarged  hemispherical  follicles  in  a  patch.  The  increase  in 
size  is  due  to  a  hyperplasia  of  the  lymph  elements,  a  process 
which  also  extends  to  the  adenoid  reticulation  of  the  patches 
and  the  contiguous  mucosa.  The  swollen  condition  of  the  lower 
part  of  the  ileum  is  largely  due  to  the  great  increase,  intertu- 
bular  and  sub-mucus,  of  the  lymph  elements.  The  affected 
patches  usually  appear  with  great  distinctness,  projecting  from 
the  mucosa  for  a  distance  of  a  line  or  two,  and  present  a  greyish- 
white  appearance.  They  can  be  seen  from  the  peritoneal  sur- 
face, and  the  portions  of  the  bowel  in  which  they  occur  can  be 
felt  to  be  thicker  and  firmer  than  contiguous  parts.  The  soli- 
tary follicles  are  not  always  affected  ;  usually  they  are  more  or 
less  swollen,  and  in  rare  cases  they  have  been  alone  involved. 
They  range  in  size  from  a  pin's  head  to  a  large  pea,  and  may 
be  very  deeply  imbedded  in  the  sub-mucosa.  In  the  caecum, 
appendix  and  colon  the  solitary  glands  may  be  greatly  swollen. 
In  Case  XXXII.  the  solitary  follicles  of  the  ileum  were  very 
prominent,  many  of  theui  almost  pedunculated,  which  gave  a. 
very  remarkable  apjtearance  to  the  bowel.     There  is  generally 


hypen 

patcln; 

serous 

follicle 

In  a  m 

in  the  i 

are  iiiv 

uppei'm 

bably  s 

sloughir 

mr.y  occ 

intjftisitj 

system. 

tlie  pate 

lated  or 

retiaulee 

very  con 

swollen  f 

rapidly   t 

usual,  I  t 

plasia,  be 

mark  thei 

from  the 

times  seen 

the  fusion 

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about  the  ; 

or  disease 

over  25  or 

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remember  t 

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common,  pa 

affections. 

latina.     E. 

1  Typhoid  E 


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in  -1.0  Lt  Lo,.o IC';  .  1:™;  1-7  «'-  on.     E.cn 

"Pr»™o.,,„;„»;,      ,":      7^"°';.-'»  ""'  often  at.ack  the 
'«'.>y  3„„si.los  witi:.,        •*;':;--  ">o  swelling  p,.„. 

■n.'J  occnr  while  the  A„,u  °  e   "i,,  "'"  ,  '""''•  "  «"»!  ^ult 
int=«.it^„r.|,efeve,.:;     ^,,"„  '■     '"  ""?  ''»=<'. -'-  '»  'Lo 

"'«  l>a<cl,es  i,  pr„d„„ed  wi.ere       C    '  r      ™"'  ''■'""''''""  °f 

-*««tf^wlnc],  were  fi  Tec,. atnir  '('"'''" '   "    ""^''« 
VCT  oe™™„„,  a„,l  n,ay        X?;  7''''"''  ''^  Ci,o„el,  are 

awoiler,  folliele.,  „f  a  naleh     rlr  ,  ™  "■^''-     '^'"'«'-  «"> 

-PKii.  t„a„  the  .n,'™!  :/7ir:r':  ""V"™^™- 
u-ai,  I  tt,i„k,  .H„  ,,,„„,„,  ai'j ::  'i; .  :■ : "' ",  ™™ 

plasm,  become  nerrnHp  n,,  j    i-  •.       "  '"tense  hyper- 

mark  .heir  plloe"  sl  ,  .  "2  "ff "'  ''""">S  ""!«  p'  to 
f™n  the  ru  ,.  ,;  of  'r  1, T;  ™'  ''""'""•'■»"-  ™y  -"it 
'taea  ..on  i„a„  niee         ^    ^''^r''     '  ""»  -era, 

ao  fuaion  of  several  of  .he,ell«To,ite  "  "'■■S'™'"'' fom 

feome  have  thoujrht  thi^-  th„     • 
»l<ontthegla,„lsintho  't    "'°  £8™'"""°"  "l"oh  h  found 

«ver  25  or  80  vol  ,f    1  ,         "  '"  """""""  """  "'  l-'»- 
't  ia  -prosente'd  rPe;^V    i  ""»{  f'''''-^"  i'  »ta»«t  norn,al. 

'■o.ne™her.h„..hi.e:ii::;^  :,«-„;«;:;  7 

«  not  peculiar  rr,  typhoid  I,,.,.,         '    i  ■?,  ■''°'''"''°"™'« 

' »"»..,  part,cula  "  wtn  d"th  his  ''•""  "  ^^""""'""'^ 

»lti!ctio„.,.     I  have  1,    r.  ■'■"'^  '"■™  '""='"■'"' 

Jalet^ivesj^e„a  account  of  it  as  n,et  with  in 


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children,  and  Brans*  discusses  the  various  conditions  under 
which  it  has  hecn  found.  While  there  is  nothing  specific  and 
distinctive  about  the  swelling  of  Peyer's  patches  in  typhoid,  yet 
in  adults  wo  raKcly  meet  with  affection  of  these  glands,  associated 
with  fever,  in  any  other  condition.  Cases  of  typhoid  occur  in  which 
death  takes  place  rapidly  before  any  distinctive  symptoms  are  mani- 
fested, and  insjiection  of  the  small  bowel  alone  reveals  the  true 
nature  of  the  disease.  Such  a  case  I  saw  not  long  since  with 
l)v.  Sinkler.  A  lady  came  to  town,  a  distance  of  several  hundred 
miles,  to  see  a  specialist  about  her  eyes,  arriving  on  Thursday 
morning  feeling  apparently  well.  On  Friday  and  Saturday  she 
was  seriously  ill,  high  fever,  temperature  reached  10") '^,  diarrhoea 
and  semi-euma.  Death  took  place  on  Sunday,  less  than  sixty 
hours  from  the  first  visit  of  the  attending  physician.  The  nature 
of  the  case  was  demonstrated  by  Dr.  Longstretii,  who  made  the 
autojjsy,  and  found  swelling  with  commencing  ulceration  of 
Peyer's  patches.  No  doubt  before  she  left  her  home  she  must 
have  had  slight  fever,  and  we  had  been  dealing  with  a  case  of 
ambulatory  typhoid,  with  sudden  accession  of  fever  and  head 
symptoms. 

2nd  Sta»jk.  Necrosis  and  SlougMnff. —When  the  hyperplasia 
of  tl'e  lymph  cells  reaches  a  certain  grade  resolution  can  no 
longer  take  place,  the  vessels  become  choked,  a  state  of  ans^mic 
necrosis  is  induced,  and  a  slough  forms,  which  must  be  separated 
and  thrown  off.  The  process  may  be  (juite  superficial,  affecting 
only  the  mucous  tissue  of  the  patch  or  even  only  a  part  of  it, 
but  usually  it  extends  to  and  involves  the  submucosa.  In 
Case  XXVI.  there  were  many  thin  sloughs  adhering  to  the 
patches,  in  which  the  follicles  and  pitted  appearance  could  be 
distinctly  seen.  It  is  always  more  intense  towards  the  valve, 
and  in  severe  cases  the  greater  part  of  the  mucous  membrane 
of  the  last  foot  of  the  ileum  may  be  represented  by  a  dirty 
brownish-black  eschar.  The  solitary  glands  may  also  be  capped 
with  small  sloughs.  They  have  a  yellow-brown  color  from  the 
bile  pigments.     The  depth  to  which  the  necrosis  extends  depends 

'  Vol.  X  TninsftttidiiK  of  I'athulQjii'jal  Society  o!  Fhil.isli^ipiiia, 


on  the  intensity  of  the  iyrnj,hoi,l  infliltration  ;  it  ,„ay  he  <leen  in 
the  muscular  coat,  or  even  reach  the  serosa,  ^  ^ 

8hd  Stage.    Uloerafion.~nc  scDaritinn  nf  fv      i      i.    • 
,„.,,, i,,„n„  „«•.,,.  stp.uation  ot  the  slou<'hs  is 

gi.Klually  effected  from  the  cd^'cs  inwinl.    nrwl  •.  -11 

with  great  a,,.,  „„a.o,daMe  ,^;:7t^'      olX':' 

Zr^;  K  ™'  'T'"""'""''^  ""=  '"""■•  "'"«''  fo™'  the 

o,.p«..to  thcnccntcicattaclunont  i,  rare.     Irro«l 7 la  „ 
.  ulcc,»  ,1  v„l„,l  1,^  »„pt,  „f  ,„„„„„,  ,„^._,_ 

r  ::„„:"■"" '"'', 't "'■"  "'^■™-  '"■« --^^'^'"^^ 

IZT       .   ';  ';"""''«''■"'"  "l.pearanee,  an,l  may  l,c  funnel- 

.ap.. ,  the  central  deeper  part  of  tl,e  ,,l„ngl,  havii,,.  reael  od 

tbrongi,  tl,e  .ran»ver»e  fibres  or  even  to  the  aero*,.  TheL    4  te 

eati,  la.  take,,  place  late  n.  the  disease,  they  a,-e  ti,i„  and  pale 
a      not  always  under,ni„e,l.     At  this  period  the  ulcc-s  „ea     , J 
va  » .  ,aay  l,ave  vc-y  irregular  sinuous  l.cdevs.  Son.etin  es  „    a 
patch  »e  n,ay  see  an  ulcer  which  has  enc-oacned  upo         ne  ,"l, 

or,ng  ,nuco„s  ,„„™„,.a„e  as  if  the  ulee,-ati„„  had  o'xte,     ,     ft 
the  sepa,,,t,„„  „f  the  „l,„,g|,.  The  base  of  a  typhoid  ulcer  i  s  „«  I 

:ca:i::',rf? '"""•''  -•■ "-  •■'™'"'-''^-  of  .nuscrz 

oocas,onally  ol  the  pentoneum  alone. 

4t,i  Sta,«.  ai»;m^._wi,en  death  occurs  late  in  the  dis- 
ase  Irom  exhaustion  or  perfora,  .v,  we  ,nay  have  an  „  porTu 

0.<«  XXJX   death  ,„  the  sevoth  week  from  septicemia  ,|| 
^heuleers  ,„  ,le„mwere  cicatrizing  and  one  ortwohad  coaple'tely 


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closed.  The  ])rocc8s  begins  witli  the  dcvolopmont  of  thin  gra- 
nulation tissue,  which  covers  the  baao  anil  gives  to  it  a  soft, 
sinning  appearance.  From  the  elgcs,  the  mucosa  gradually 
extends  over  this  on  all  sides  with  a  new  growth  of  e])itheleum. 
The  site  of  a  healed  ulcer  is  a  little  depressed,  and  is  marked 
by  pigmentation.  C)ccasionally  one  sees  an  appearance  as  if 
an  ulcer  had  healed  in  one  part  and  was  extending  in  another, 
but  this  is  unusual.  In  some  instances  of  relapse,  with  ulcers 
healing  in  places  there  arc  fresh  ulcers  higher  up  in  tlio  bowel 
and  patches  in  a  state  of  hyperplasia.  Theoretically,  we  may 
assume  the  healing  to  begin  so  soon  as  the  sloughs  have  sepa- 
rated ;  indeed,  when  resolution  is  impossible,  the  removal  of  the 
necrosed  parts  is  itself  the  first  stej)  in  the  process  of  repair, 
but  practically  wr  do  not  often  in  fatal  cases  meet  with  evi- 
riences  of  cicatrization.  The  majority  of  death  occur  before 
ihis  stage  is  reached. 

Large  Bmvel. — The  caecum  and  colon  are  freciuently  adected, 
but  not  to  a  severe  degree.  In  nearly  a  third  of  the  cases  there 
were  ulcers  in  the  caecum,  and  the  solitary  glands  in  this  [lart 
and  in  the  ascending  colun  were  greatly  swollen.  In  GiXse 
XXJll.  the  glands  in  the  ileum  were  very  small,  while  in  the 
larger  bowel  they  were  very  prominent.  In  one  instance  there 
was  an  ulcer  in  the  appendix.  In  1877  I  di.ssocted  a  case  at 
the  hospital,  in  which  the  patient  died  three  or  four  months 
after  an  attack  of  ty|)hoid  tever.  The  ai)pendix  was  perforated 
and  surrounded  by  a  localized  abscess,  and  there  was  intlanuua- 
tion  and  suppuration  of  the  mesenteric  and  portal  veins  witli 
empyema. 

Many  cases  of  perforation  of  ciecum  and  of  appendix  in 
typhoid  fever  are  on  record. 

Perforation. — In  eleven  instances  death  was  caused  by  per- 
foration and  peritonitis.  Of  the  ten  cases  in  which  it  was  noted, 
the  orifice  was  found  in  seven  within  H  inches  of  the  valve. 
In  only  one  was  it  distant  18  inches.  In  Cane  XL.  there  were 
two  perforations — one  at  a  distance  of  7  inches,  the  other 
2-\  inches  from  the  valve.     In  five  cases  the  perforation  was  in 

I 


11 

"Ic<T3  from  which   the  slough,  had  separatcvl,  but  i„   three  of 

.eso.t  appeared,  f.u.n  the  condition  of  the  other  patches,  that 

.0  pe  torat.on  was  du-ectlyduc  to  th.  extension  of  the  no  rosis 

hrou,h  all  the  coats      In  only  tw.  the  perforation  at  the 

'>ot  om  of  clean,  tlnn-walled  ulcers  Ca.e.  1  the  fatal  uJt 

could  he  d„.c.tly  traced  to  an  ir.di.s.,retion  in  diet  nearly 

ooks  aftc.  the  temperature  had  l.en  norn.:.l.     f,.  ,,  „,,,L' 
tl.o  sloughs  were  still  partially  adherent  ahout  the  site  of  ^.f" 
ration.  _  A   majority  of  the   cases  were   in  small,  deep   ulcers 
1  ontorufs  was   present  in   every  case  ;   in  two  it  was  localized 

111  "7  f ''""""'^'  ="'•  ''^'^'«  -"'«"-  i"  --eral  instances 
the  base  of  u  cers  was  formed,  wholly  or  in  part,  of  thir.,  .rev- 
jsh  pentoneal  fssue,  evidently  necrot.c,  and  ,reat  care  Imd  'to 
1)0  e.xerc.se.1  to  prevent  t.-arin^'  in  removal  of  the  bowel  I 
have  o,.ce  o,.  twi.e  seen  the  serous  coating  covered  with  thin 
flakes  of  lymph  m  the  vicinity  of  s.ich  patches. 

//.m.n-V,.  occurred  in  nine  cases,  and  contributed  directly 

•    'Hl-c  ly  to  the  fatal  result.    In  two,  perforation  also  occu' 

•       ..  five  there  was  blood  mure  or  less  altered  in  the  c.ccun. 

and  colon  ;  n,  one  case  in  the  ileuu.  itself.     In  most  of  the  eases 

c  b  eedn.g  see.ned  to  result  directly  from  the  separation  of  the 

Ploughs,  but  u.  no  .nstance  was  the  bloeding  vessel  found,  not 

cwenm  r...  .LLriV//,,  i.  .hich  only  one  ;tch  had  slou./hed 
a«'<l  the  clot  was  still  a.lherent.     The  soft,  swollen  cb-es  of  ,he 
■;;;;;^;es  ...ay  have   been   the  seat  of  bleeding  in  oiie  or  two 

Jf.«..^mVy.../«_E.xcept  in  two  or  three  cases  in  which 
cath  took  place  late  u.  the  disease-,  the  group  corresponding  to 
.0  .leum  was  u.variably  involved-swollen,  sometimes  congested, 
".0.0  often  m  a  state  of  intense  hyperplasia.   I  have  seen  s<,ftenl 
u.g  and  suppuration  in  several  cases  ;  the  softening  is  apparently 
due  to  an  amem.c  necrosis  similar  to  that  which  affects  the  lymph 
cotnents  o    the  bowel.     The  glands  may  be  very  deepl/con 
tc^  and     have  found  in  such  specin.ens  many  cells  L'ntain- 
...y   ed  blood  corpuscles.     As  has  long  been  known,  there  are 
.n  addUjon  to  the  ordinary. lyn.ph  ceils,  many  large    cells  S 
two  or  three  nuclei. 


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Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  ;4S80 

(716)  872-4503 


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Sfh'i'n. — Moderate  enlargement  of  this  organ  constantly  takes 
place  in  tvplioid.  It  is  rare — in  my  experience — to  be  able  to 
jtalpate  the  anterior  edge  under  the  left  costal  cartilages.  Of 
35  instances  in  which  the  weight  was  accurately  noted,  in  only 
one  case  did  the  organ  weigh  over  20  gzs.  ;  in  three  about  19  ozs. 
In  four  cases  the  weight  was  below  the  average. 

Complications — Puhnonarij. — The  hypostatic  congestion  is 
almost  always  uiot  with  when  death  occurs  slowly.  In  6  instances 
there  was  actual  pneumonia,  in  2  siuii)le  {)leurisy,  and  in  1 
empyema. 

Pjiaimia. — In  '^(ue  XlT/Z/the'-e  were  suppurating  infarcts 
in  the  lungs,  and  in  t'ase  X.VXl  1 1  infarcts  in  spleen  and  kidneys. 
In  neither  ease  could  any  disease  other  than  the  intestinal  be 
discovered. 

Thrombosis. — In  C^ase  IX,  the  right  circi'mflex  iliac  veins 
were  distended  and  fdled  with  linn  thrombi.  The  superficial 
veins  on  the  right  side  of  the  abdomen  were  enlarged  and  |)romi- 
nent.  In  Case  XXIX,  in  the  6th  week,  a  thrombus  formed  in 
the  left  femoral  and  iliac  veins,  and  in  the  former  proceeded 
to  suppuration,  with  intense  phlebitis  and  involvement  of  tiie 
inguiiial  glands. 

Diphtheritic  affectijm. — Secondary  membranous  inflammation 
of  the  mucous  surfaces  is  .arc  in  typhoid  fever.  Louis  mentions 
three  cases  in  which  diphtheria  arose  us  a  complication,  and 
Murchison  states  that  he  has  had  several  examples. 

Six  of  the  cases  I  have  dissected  presented  more  or  less 
extensive  inHammation  of  a  croupous  or  diphtheritic  character. 

(\itic  I  (No.  12),  female,  aged  2o.  No  special  clinical  features. 
Mucous  membrane  of  pelvis  of  left  kidney  covered  with  a  firm, 
greyish-white  membrane,  which  could  be  stripped  off  in  th';  form 
of  a  mould  of  the  parts  ;  deep  congestion  ot  subjacent  tisPues. 

Case  II,  woman  aged  -55,  admitted  Nov.  25th.  Had  been  ill 
for  about  two  weeks.  The  case  was  tolerably  severe,  and  lasted 
over  eight  weeks.  Temperature-range  during  the  first  fortnight 
in  Hospital  was  lO^*^  to  104.5'^.     On  December  Hist  it  became 


13 

normal      There  was  a  good  deal  of  nervous  depression  through- 
out. She  had  retention  of  urine,  and  was  eatheterized  on  several 
occasions,  the  first  time  on  Dec.  4th.     On  the  14th  there  was  a 
bloody  discharge  from  the  vagina ;  on  the  2;3rd,  l.loody  urine 
and  from  this  time  shreddy  matter  was  passed  from  the  bladder' 
ihore  was  great  pain  on  the  passage  of  the  catheter.     Urine' 
not  dimuushed  in  amount.     Death  on  Jar.,  .".rd.     Tcmr.erature 
normal  for  four  days  before  the  end.     At  the  autopsy  hoalin. 
u  cers  were  fo.nd  in  ileum.    Spleeu  9r>  g,ammes.    The  co.niitio;; 
ot  the  gen.to-urmary  organs  was  as  follows :  Kidneus  not  en- 
larged substance  pale.     On  section,  the  pelvis  and  calyces  were 
covered  with  a  th.ck  greyish -yellow  exudation,  in  the  left  organ 
nvolvrng  the  entire  membrane,  in  the  right  only  the  upper  third. 
.The  surface  of  the  exudation  was  rough,  and  on  secUon  it  was 
een  to  extend  deeply,  in  some  places  3  m.  in  thickness.     It 
ould  not    e  hfted  off  the  mucosa,  but  infiltrated  it.  The  papill. 
ir/    I  "fr"  "'''  ^^''  '''''''^-     '-The  ureters  were  not 

miter  !i  n  J  T'"'''''^  '  ^^"^""^^  '^  greyish,  shreddv 

mtenal  and  a  membranous  cast  of  the  upper  pari  of  the  organ, 
which  had  separated.     It  was  about  2  m.  in  thickness,  and  wa 
begmmng  to  d.su.tegrate.  The  p^ .  ts  about  the  neck  were  covered 

with  a  th.ck  grey.sh  exudation,which  was  with  difficulty  detached 
In  the  cen  ral  zone,  there  were  many  isolated  patches  nrojecti,.: 
j-4  m.  Ihe  wall  was  of  a  dirty  greenish  colour,  and  was',  in  the 
greater  part  of  its  extent,  denuded  of  mucous  memb.-ane.  The 
onfice  of  the  urethra  was  free,  but  the  tissue  about  it  was  h>Bm- 
orrhagic  Fayma-Mucosa  in  the  laterp.l  walls  covered  with 
a.  greyish  membrane,  which,  in  the  right  side  extended,  to  the 
OS,  covering  part  of  its  margin.  Towards  the  vulva  the  mem- 
brane surrounded  the  entire  canal.  It  cou'd  be  stripped  off  in 
nakes.     Ihe  uterus  was  normal ;  no  exudation  in  its  cavity. 

am  r/Z  (No.  3(j),  male  (young),  admitted  Feb.  22nd,  with 
well-marked  typhoid  fever.  All  symptoms  mild,  except  the 
diarrhoea  which  was  difficult  to  control.  Pain  and  tympanites 
were  troublesome.  He  was  doing  well,  temperature  had  not 
once  reached  108°,  when  on  March  4th  he  complained  of  sore- 
ness ,n  the  caruncles  beneath  the  tongue,  and  there  was  swelling 


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beneatli  the  cliin  at  a  corresponding  point.  The  sore  part  was 
touched  with  nitrate  of  silver.  On  the  morning  of  the  Atli  the 
swolHn"'  under  the  jaw  had  bec'-me  more  diffuse.  U[)  to  tliis 
time  no  incroase  in  temperature,  wliich  was  101 '■\  and  the 
•General  symptoms  did  ^.ot  indicate  any  serious  chan<je.  ^n  the 
evening  the  neck  had  become  greatly  swollen,  and  there  was 
exudation  on  the  (jharynx.  Tem[)oratare  102^",  Voice  husky. 
Swallowing  im|)Ossihlc.  Pulse  weak.  He  passed  a  bad  night. 
and  on  the  Gth  died  asi)hyxiated  at  2  p.m  rather  unexpectedly, 
as  at  1  p.m.  the  laryngeal  symptoms  were  not  very  marked. 
Temperature  at  11. CO,  105°.  The  autopsy  showed  mary  ulcers 
and  sloughs  in  lower  part  of  ileum.  There  was  great  infiltration 
of  all  the  tissues  of  lateral  and  anterior  regions  of  the  neck. 
Two  small  losses  of  substance  on  either  side  of  frajnum  lingme ; 
oedema  of  pillars  of  fauces  and  uvula.  Posterior  part  of  soft 
palate  was  covered  with  a  greyish  membrane,  which  extended 
into  the  nares  for  a  short  distance.  Posterior  wall  of  pharynx 
covered  with  a  similar  membrane.  Membrane  on  upper  surface 
of  epiglottis.  (Edema  and  swelling  of  laryngeal  folds  ;  no 
exudation. 

Case  IF  (No.  50),  male,  aged  39.  Oraui,.iy  course,  until 
perforation.  No  special  symptoms.  Pelvis  of  right  kidney 
inflamed  and  covered  with  a  thin  sheeting  of  firm  exudation. 

C(tse  V  (No.  51),  female,  aged  43.  Course  of  moderate 
intensity,  and  then  severe  laryng(  al  and  bronchial  syrajitoms. 
Many  large  ulcers  in  ileum.  iiJxtensivo  diphtheritic  laryngitis, 
and  a  uniform  membrane  extended  down  the  trachea  and  into 
the  tubes  cf  medium  size. 

Case  VI  (No.  52),  female,  aged  18.  Death  from  the  fever 
and  exhaustion.  Many  intestinal  ulcers.  The  vagina  presented 
several  patches  cf  firm  membranous  exudation,  beneath  which 
the  tissue  was  deeply  congested. 

Cases  II,  III  and  V  may  be  regarded  as  instances  of  true 
diphtheria  occurring  in  typhoid  fever  ;  the  other  cases  as  exam- 
ples of  local  membranous  inflammation,  such  as  we  meet  with 
from  time  to  time  in  the  specific  fevers. 


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CONTKNLS. 


.Sarcoma  of  Jcft  frontal  l„l,e 

l^-boii«m  of  left  antoWoreorobral  artery 


PAOI 

3 


Three  cases  of  abscess  of  the  liver  ■''•••       4 

Two  cases  of  cancer  of  the  stomach         '''■•■       '"^ 
Hernia  of  cfecum  and  an.jenrJIv  .."'*••» 

p.o-,>..eu,„„..„.,.,„  „„x:,t:: ."°''"™'-™  <"• '--  .-i'»"i«.  .0 

Retroperitoneal  spindle-reJl,. '  "         *         •         •         •     12 

changes        .         .         _        '^"'"'^  '^'^'>  extensive  thrombotic       "^ 
Cirrhosis  of  liver  fifnJ  k  •  "         '         "         •         .     13 


Aneurisms  of  the  Wer  cerobrnl      .    • 

A         .  "       ^'^^'^' '"'Series ;  twelve  c'.so« 

Aneiir'"'"  "^  ^'     ■'  "^'vc  cases 


'J-isni  of  the  thoracic  c 


aorta 


;  perforation  into  left  pleura  . 


19 


Small  aneurism  of  arch  of  anrh,  '  ' ^'^  ^"'''"'''  '         '     25 

trachea         .  ^'''' '  ««'»Pres«ion  and  perforation  of 

Aneurism  of  the  nrfl, .  ,     ^       .  **'*•■ 

H.^..reofJ::lr:"^"!^^-^^--^-pbagus        . 


posterior  papillary  muscle  of  left  ventricle 
I  ^:^'"  ^'"«^«  «f  ^--r  pulmonary  valves       . 


26 
27 
30 


Lai 


'cuspid  pulmonary  valve 
■ge  phlebolith  of  long  sapl: 


lenoug  vein 


31 
32 
32 


N 


1 1 


'I! 


l|: 


I 


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1      1.^    Ci 


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I 


CONTENTS. 


On  the  morbid  anatomy  ol"  pnenmonia  . 
Aspergillus  from  tlio  lung       ... 


Case  of  Addison's  disease  (with  Dr.  J.  C.  Wilson) 


PAoa 

.     41 


.     42 


The  hicmatozou  of  malaria     .         .         .         .         .        . 

Intestine  of  dog  with  ticnia  echinococcus  in  sihi     .         ,         . 
Cysticercus  cellulosio  in  heart,  brain,  and  muscles  of  pig 
Calfilication  and  dilatation  of  the  bile-ducts ;  the  effect  of  flukes 
Hydatids  passed  with  the  urine 


45 
6(5 
G7 
07 

08 


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u 

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k 

^''"•''^^^  of  the  left  frontal  lobe. 
Unknown   man,  ad„,iK„,  Deron.bor  K,l       ,r 

'"'•'  «''«''t  fbvor,  l,„t  no  local  ,  In  '  "'"■''  ''"'  '''H'lM-iatc.s.     He 

I''»-  on  tl,o  third  day.  '^'''^"^"  ^■""'''  ''«  J^'^^-otcl.     Death  took 

"-Late Iv  ahovo  the  left  olll.e    ,  -        ,*    ;    ':"^'^'"''''^'  "--•  '•''ia.sn..     !,„. 
j   obnun  substance  beneath       f^     '^r  ""?•''""""' '■""^-^"'• 
dollar  was  ecchymosed.     Vessel.  o^'liMv'-,?'   '" '^'^^  ''' '^  quarter 
«t."g  the  longitudinal  sinus  the  nl    I       '     ^^''"'^  "'"''""'•     0"  «'Par- 
-^^"-;  "0  extravasation.     T      Z^T  '''''^  -"'^-'ed  an.l  .!;de. 
-e-  unusually  distended  with  llood      n'   T  ""^'  •^"'"'^'  ^*  ^^-  base 
ve-ns  were  very  full.     The  J^:^^:J^  ^  ""'"'^  ^^'  ''''  ^•-»  ^''e 
prominent.     The  left  fronfd  Z       '"'' "''^'' ^''e  convolutions  were  verv 
by  Puros' method,  the,':;    l^::;-;-''^;'-     ^"the  ft-ontal    i:^ 
"g  the  anterior  extrenutv  of^l      fl    "m    " ''''''''''  ^^^-'^  ^^^m- 
apox  ;  at  its  lower  part  it  M-as  cvstic  -in  /'!'"\'^-^^^"'''-ng  close  to    he 

«ocon,l  section,  cut  at  a  distunrof- two  "??'"'  "  ■^"'"""•'■^''  «"!^'-  The 
0^1  olando,  expose,!  an  infi  t"!^^^^^^  "';  '  ''^^'^''''^''es  fron.  the  fissure 
no.ghborhood  was  n.uch  swt^\l":  '""«'•  ^''^  "'"'--'^tter  i„  tl  e 
'"""-iatoly  through  the  bas  f  th  T^T''  "^'^  ^'''••<'  -^^-n 
7';'"'^'  "^"^«  -atter.  Thissect  at  "'"''"'"'""'""'  '""'''''^  ^ 
0/  the  corpus  striatum.     Sectio    tl  .m    •     """^  '''"^''■'"'-  ^^'^''^'^i^V 

;  -ved  no  change.     Section        1    ^.^"^'^^  ^^"tal  convolution 

«  oaths  swollen  ;  no  neuritis.     eTJ   '  tio    'T  °'':  '^''  ''''  ^^^^^'^^l  the 
gbosarcoma,  with  cells  of  larger  s^ri';""'/'^  ^""^^"  ^'^  ^^  ^ 

I'suai        Jan  liar)/  27,  1887. 

7.He::L  ;-s:^ri;-j;7  thighando,,."  ' 

^^^t- admission  with  syn.ptoms  of  co„f''^^^^'  P^^^  ^^-t  ten  days 


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Ih-aiii:  The  left  frontal  lobe  tore  on  removal,  and  a  soft  i)urifbrm 
flnid  exuded.  This  lobe  looked  flatter  and  was  softer  than  the  otlier. 
At  tlie  liase  vessels  looked  natural,  a  few  thin  i)lates  of  atheroma.  On 
tracing  anterior  cerebrals,  the  left  vessel,  three-cjuarters  of  an  inch 
beyond  anterior  communicating  artery,  was  swollen,  became  tortuous, 
and  was  closely  united  to  the  inner  face  of  the  iirst  frontal  convolution. 
At  thirj  i)oint  the  vessel  walls  were  thin,  looked  infiltrated,  and  of  a  grayish 
color.  At  the  region  of  softening  on  the  walls  of  the  artery  tlie  two 
anterior  cerel)rals  were  'ulherent  together.  The  vessel  was  ])lugged  for 
the  lengtii  of  three-(juarters  of  an  incii,  lirra  except  at  the  spot  above 
referred  to,  where  the  walls  were  quite  soft.  The  first  frontal  convolution, 
as  far  as  its  base,  was  softened.  On  section,  there  was  a  distinct  puriform 
softening  at  the  apex  of  the  left  lobe.  In  the  white  matter  this  extended 
back  to  the  anterior  horn,  gradually  becoming  less.  Superficially  it 
involved  the  anterior  part  of  the  third,  the  gray  matter  oi  the  anterior 
portions  of  the  first  and  second  convolutions  not  much  involved.  Small 
foci  of  softening  in  the  inner  section  of  the  left  lenticular  nucleus  just 
above  anterior  i)erf'orated  space.     No  further  change  noticed  in  brain. 

There  were  no  thrombi  in  the  femoral  veins.  Heart  normal.  There 
was  suppuration  at  the  seat  of  the  fracture.  June  9,  1887. 


Hemorrhagic  pancreatitis,  n'ith  swelling  of  the  semiltniar  ganglia,  and 

Pacinian  corpuscles. 

The  specimens  were  removed  from  the  body  of  a  man,  tct.  58  years, 
whose  lungs  were  emj)hysemat()us  to  a  remarkable  degree,  and  whose 
body  presented  slight  axleina,  accompanying  the  heart  trouble  due  to 
emi:>hysema.  Tlie  Pacinian  corpuscles,  about  forty  in  number,  were 
found  in  the  connective  tissue  behind  the  duodenum  and  pancreas, 
showing  as  bluish-white,  translucent,  rounded,  ovoid,  or  reniform  bodies, 
with  a  central  white  axis.  They  varied  in  size  from  the  largest,  G  nun. 
long  by  4  mm.  thick,  to  some  not  larger  than  normal.  They  were  all 
plainly  attached  to  nerve  filaments,  most  of  them  scattered  and  single, 
a  few  in  groups  of  three  or  more.  The  increase  in  size  was  due  to 
an  oMlcmatous  condition  of  the  concentric  sheaths.  Tliis  form  of  en- 
largement of  the  Pacinian  corpuscles  seems  to  have  almost  completely 
escaped  observation,  for  it  is  not  referred  to  in  any  of  the  text-books  on 
morbid  anatomy;  but  Dr.  E.  Przewoski,  in  Wrchow's  Archiv,  Bd.  Ixiii., 
describes  five  cases  yi  which  tliese  bodies  were  atfectcd  in  this  way.  In 
two  the  subjects  were  (edematous,  and  it  is  probable  that,  if  looked  for, 
they  would  not  infrequently  be  met  with.      The  semilunar  ganglia. 


Hi 


-  ;;  "  "'-lines  and  in.li.tin.tn  "      ^^ '  "'""?'•  "^"  «-'"  --'-I  coJJa, 

i''«  pancreas  presented  an  ;,  ^"""''""  '^^'"«- 

-tivo  .i..,e.J  fined"-re     :;::;;  tr-     ^^••TwHoretheeon. 
the  ease  toward   i|,e  tail   wl.ore  ""''"'  ^'""^^^     E«peciallv  was  this 

^-'y<'^tl.o  gland  the  aci,„'::,7'-^  ""'•  ^^^"'^'  ^'"^^     J"  ^o 
-  |.'--h.white  areas,  .ur...u:;^t72Z  Ti"'"''  ""'  ^^^^^^^ 
■0'  •      il.e  loose  tiss„e  in  the  nei^hbL  '    ,  '^■"""•'"'tnc  exuda- 

K  ;^l's  g.ves  a  ,.,od  aeeonnt  of  h  n  '  "^  ''"''  "''''^''''t^^'I  "ith  serum 

col  eeted  several  cases  in  whi.!  '"\^  7"  ^'^  Pancreas,  an<l  hTs 

a-'  tins  .as  the  on],  lesion  fbn.ul      Th    ^  ,  ?'''"  '"  '^  ^■^"•>'  ^'-^'^  ti„,e 

^  ■«  ;-o  co„.p,ai„ed  f;>r  several  <h^  i^C"""'  "l'-  ^•^-     '^^'-  1-tiontin 
-'•  -s  also  ven-  sensitive  to  ^^^T  '""  "\  '"  ^P'"-^-""' 
"'"f  •  ''"^^  '^  "as  thought  possible   -si  eh    ,    '  ''"''''^  ''  *''^^  ^^'■i=^''fest 
^-•'1  appearance,  that  he  Ini.l  t  -n  ^  ■^^"^■■^^''  ''"''  '-'  a  hag- 

-- .-f iHng  fbnnd  to  acconnt'fbr  tl "  .i  Z'"'""'  ",  ^'"  ^'"'-'"''-  The^ 
-n.lnnar  ganglia,  and  tl,e  con,  .^  r^"''  '"""'^'"^  ^^'^^^^^'^I- 
J^'o  nn,de  of  death  was  ,,ec..Iiar       T  "'  r'''''  '''"'^-^  ^'oscribed. 

f '-  a  tolerably  eon,fb,,ibIe  ,1,,  ^  ^    i""",  "^  ^'"^''^^^^  -  "-al 
^^■'"'<'  ""^"'lant  lying  on  his  side    V     •  "^''"'"'^  "='«  ^••""<'  '»'  the 

a  ^tra,.ge  n.anner.  Vhen  s<^  Ct  e'"  '  1  "''  :'"'''  '"^  '^-^''4  ia 
-';J<I />o  ronsod,  but  the  pul^  ,  ,•  "'"•'r"^'  ^^^  F-  A.  Packard? he 
-'^  t'-e  was  typical  Chev     ^^  ^:  ^'J    ';!'i--ptible  at  the  wH^ 

PO"o,Is  of  apncea.     I„  this"  .f.te  L    ''T       '"''  "'"'  "»"«"a]lv  lon^ 

took  place      Tl.,w.i       i  '°  contnnied  till   1  I  '^n  ,.  i      "  /    ^ 

IMce      i  he  chambers  of  the  hea,.f   ,..,,,•     ,        ^^••^«.  when  death 

■^^■.  wore  fb.Hui  to   bo  dilated.     Ti  «   k!.  •     ''"''"•'•^-  ^''^^  "^'  ^I-  Hght 

'posted  in  these  cases  that  the  r ,  >1,       "  "''  '"•'•'"^^'-     ^^  has  b^en 

">"  or  the  heart,  induced  bv  f  :"''  ^'7  '?  '"'  ^"  '•*'"-  -''i^i- 

"'ay  be  supposed  to  occur  when  he  "   ' '"  "'"^  ^"''"-  I''«-^"-^.  which 

«"<!  adjacent  tissues.      It   T  .  ""^'  ^'^'^^^^  '''"^^  '"f-  tlu'  pane  ^ 

in     ,..!,•     1  '*      <lnalO<r()|iq     f,,      /I     1,     ,  .  |"ilU  ILilS 

'^""K'rru  -^,  1S8(5. 


^/i've  «,.,-.s  of  al>.cr.,  of  Uvcr. 


Cask  I.    Cln-onir.  dmcntcn,  ■  //     , 

""^''^^'"'-'^''''''-^-p^-AugSt^^r-,^^ 

^•^  iiau  typiioid 


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L^  0    ■! 


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Will 


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if 


if 


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6 

fever  when  lilleen  years  of  age.  Two  years  ago  tlie  present  t/ouble 
began  witli  pain  in  abdomen,  vomiting,  and  diarrluca.  At  times  lie 
would  be  better,  but  not  for  long.  Tliej-e  was  blood  in  the  stools  at  first, 
and  he  had  nuieh  burning  pain  in  the  rectum  during  defecation.  At  time 
of  admission  he  had  four  or  live  soft  stools  daily,  not  containing  blood. 
He  had  slight  fever  at  first,  but  subsequently  the  temperature  was  nor- 
mal. He  had  lost  flesh,  and  had  a  sallow,  cachectic  appearance.  He  had 
chills  and  fever  shortly  after  the  trouble  began,  but  none  during  his 
stay  in  the  hospital.  On  September  18th,  the  following  note  was  made: 
Abdomen  flat,  veins  not  distended  ;  epigastrium  prominent,  and  on  pal- 
pation a  firm,  smooth  mass  is  felt,  occupying  the  entire  region  from 
the  navel  to  the  steriH;m.  An  indistinct  edge  can  be  felt  a  little  to  the 
right  of,  and  also  below,  the  navel.  To  the  right  the  mass  does  not 
reach  the  nipple  line,  and  here  the  fingers  can  be  placed  beneath  the 
costal  border.  The  nui?s  is  extremely  tender  ;  it  moves  with  inspiration. 
In  the  sternal  and  right  parasternal  lines  the  liver  dulness  is  dii'ectly 
continuous  with  that  of  the  nuiss  in  the  epigastrium.  In  the  nipple  and 
mid-axillary  lines  there  are  four  and  five  inches  of  liver  dulne?s.  On 
October  llth,  the  note  was:  Mass  above  the  navel  rather  more  promi- 
nent, still  very  tender  ;  it  cannot  be  separated  from  the  left  lobe  of  liver; 
right  lobe  certainly  not  enlarged.  The  vomiting  was  variable  and 
latterly  was  not  so  troublesome.  He  continued  to  have  two  or  three  soft 
motions  daily.  The  enmciatioii  and  weakness  became  most  profound, 
and  he  died  on  Novend)er  10th.     rost-morteni  notes  as  follows: 

Body  extremely  emaciated  ;  abdomen  de])ressed.  On  incising  the 
abdominal  wall,  an  abscess  was  opened,  which  is  between  the  j)eritoneum 
and  right  lobe  of  liver,  and  extends  for  an  inch  from  ensiform  cartilage 
to  navel  ;  this  communicates  directly  with  an  abscess  cavity  in  tlie  right 
lobe  of  the  liver.  There  is  no  peritonitis.  Omentum  is  adherent  at 
the  rij;lit  lobe.  The  right  lobe  of  the  liver  does  not  extend  beyond  the 
costal  border.  The  left  lobe  extends  three  inches  below  the  ensiform 
cartilage. 

Stomach :  A  little  distended  ;  contains  a  quantity  of  semi-digested  food. 
The  ])ylorus  is  free,  nnicous  membrane  soft  and  congested.  In  the 
opsophagus  just  above  the  cardiac  orifice,  there  is  an  oval  tumor,  about 
the  size  of  a  bean,  which  is  subnuicous,  freely  movable,  and  on  section 
is  firm,  grayish-white  in  color;  looks  like  a  sarcoma.  The  duodenum 
is  normal.  Orifice  of  the  bile-duct  pervious ;  a  clear  bile  fh)ws  out. 
The  duodenum,  one  inch  below  pylorus,  is  closely  adherent  to  the  hilus 
of  the  liver,  and  on  s  jueeziug  this  organ  pus  flows  from  two  orifices 
through  which  a  leil  iiencil  could    be  passed.     The  tissues  in  gastro- 


abscess  cavity  l.as  porfbruted  fn>,„      f ]  "r  s  .1,  f'     "'""""'  "•'^^''  ^^ 

externally.     This  abscess  is  the  sixe  of  1  '  ''"'''  '''"*  ^^'"^  ^^''^'ent 

P"s ;  it  is  lined  by  a  thick  m      b  'l     it      '""'"  '"'  ^"'^"'^  '-^  «--»y 
duodenum;  it  is  confined  toZ^Z:^  ZT'''''^''' ^''''''y '''''^  ^ 
The  right  lobe  of  the  liver  is  fin     ?d  t  :"^"l'!"--  I-«  of  the  Jobe. 
TJie  colon  is  thickened  thl  T  ^^^''^  '"  ^"''^''^etion. 

places  ulcerated^  •;;  ;^ rri:::f '•"^^''  T''^'-'  -^'  "^  --y 

The  prominence  of  H.n  "  7        ''^^^"^eric  condition.  ^ 

P-gressiveemaciation,  leltTr;i;:;nf  t.c'"T  f"'"^^'  «-'  ^^^ 
this  case.    On  two  occasions  a  carefid  IV  "^  ^^'"  ^^omach  in 

of  deciding  whether  the  „        Zf    «-^?""'f  ^lon  was  made  with  a  view 

;-  fonnd  practicable.  sXi  Tr:  ::f  ^  !'"-'  ^^  '^  - 
tinal  symptoms,  which  had.  however  nl!  T  ^  '''^'  "P""  ^''«  "'^es- 
treme  sensitiveness  of  the  n^s  a  .oi  'T  .  T''  '''"'^'-  '^'-  ^x- 
n'ore  than  tiie  ordinarv  p.in  '  ,^  t  ^  '"^^  ''^""*^'  ^'  ^'  "'as  much 

Case  II.     Aente   .^.^    /    m"      '""r'"'^^'»"""^  ^^'■--^• 
McB..  .et.  50  years.    ZlJl^  ^  ^^  I    t^^  V!.  f"-  -  ^"^^ 
ten  days  with  diarrhoea  and  great  n  in  i^  , ,       f  ;    ^^"^  '^^^'^  ^"  ^^I^o^t 
about  and  tried  to  work  untilal  v  d    V)   f      '^:'""'"-     ^^^  '^'^^  kept 
been  healthy,  but  had  heen^^Z^!  ^^efore  admission.    Had  always 
i7th,  appeared  to  be  in  co   "    " L  'Ze    ?"'?     ''^^"'^  ^^^  ^  ^^e 
and  .ry;  respiration  50;  pni^i^^l^lZ^^''^^''  ^"^^^"^  ''^'•'•'' 
tended,  tense,  and  drum-like    and  evh.  Abdomen  greatly  dis- 

tynipany  everywhere;  live    mlht,       ''"'^''  '^"^^'•-      *>»  Pe'-cussion, 
There  had  been  vomiting     h^  I;  T,  1"  '"'""  '^'"""-'-d 
continued  ;  the  stools  sn^dl ;  m  c      .u  f'"'     '''''  '''''-''^^^^  «*"! 

perature  was  102^  on  the  ev en         f         "  '       ^'^  ^'""^-     ^b.  tem- 
•ng  of  the  17th,  and  rose  to  100^  ^n       T"' ""'  '"  ''^  '^"  ^''^^  »'«- 
^   B-lv   that   of  a   nuddle-a!ed       e    1  h7V"^'  '^'""  '^'^  ^^^•'^^^>- 
tended.     Right  inguinal  henda      S " f     ;       '"'"•     ^^^'''^'""^  ^is- 
and  here  and   there  flakes  o     IvnS    ov  ;    "l'""  ''"""''y  '''''^'^^' 
enornK,nsly  distended,  the  transver  fn  '"    '™-      ^'''^'  ""^"^^^ine 

partof  ,u-m      In  ^,    /    ,    ''^''"^^ei^e  portion  equal  in  «\ye  to  (h;  1     , 
I  -  .11  Ml.     in  sjjots  the  Dcritonenl  a,„.f  'o  inickcst 

and  the  wall  of  g,t  had  iV   ,  n^      ''''^'''.'' '''''  covered  with  lymph 


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8 

Larr/c  intestine:  Caecum  was  tliickencd  and  inflamed.  The  membrane 
was  in  enormous  folds  transversely  placed,  blackish  in  color  outside,  and 
sphacelated  in  places  to  a  depth  of  from  three  to  five  lines.  This  condi- 
tion extended  up  the  ascending  colon  and  was  very  marked,  also,  in 
transverse  and  descending  portions.  Some  of  these  necrotic  areas  were 
isolated  and  ranged  from  a  (juarter  to  half  an  inch  in  size,  and  presented 
a  cap  of  dark  gangrenous  tissue  suiTounded  by  a  zone  of  grayish-white 
tissue  from  a  (puirter  to  half  an  inch  in  diameter.  The  necrosis  in  some 
of  these  spots  extended  through  to  the  peritoneal  coat. 

On  the  right  side  a  knuckle  of  the  lower  portion  of  the  sigmoid  flexure 
was  nipped  in  the  inguinal  ring,  projecting  about  an  inch  beyond  the 
level  of  Poupart's  ligament.  The  hernial  sac,  when  opened,  was  about 
the  size  of  a  small  orange,  contained  lymph  and  serous  fluid,  and  at  its 
upi)er  part  the  knuckle  of  intestine  was  thickly  covered  with  lymph. 
The  orifice  of  the  ring  was  large ;  the  portion  of  gut  was  adherent  only 
to  the  inner  and  lower  aspect. 

On  slitting  open  the  sigmoid  flexure  and  rectum,  a  knuckle  of  bowel 
was  adherent  to  ring  as  above  described.     From  within,  the  mucous 
membrane  was  dark  and  gangrenous ;  the  gut  for  a  distance  of  three 
or  four  inches  above  and  below  this  part  was  greatly  thickened ; 
mucous  membrane  sphacelated. 

Stomach  (ohI  ihiodennm  presented  no  special  changes.  The  small  in- 
testine was  swollen  and  presented  no  lesion  of  the  mucous  membrane. 

Liver  looked  normal.  In  the  right  lobe  were  two  spots,  the  size  of  large 
marbles,  of  a  grayish-brown  color,  well  defined  from  liver  substance,  yet 
without  a  linnting  capsule.  These  spots  represented  the  commencement 
of  a  hepatic  abscess.  On  further  incision  of  organ  there  were  three  recent 
abscesses,  the  size  of  oranges,  softening  at  centre  and  presenting  fragile 
necrotic  liver  tissue  at  periphery. 

Cask  III.  Chronic  phthi-<is;  multiple  small  abscesses  in  liver. — M.  13., 
admitted  to  Phiiadelphia  Hospital,  June  6,  1885.  The  clinical  history 
of  tlic*caso  is  of  interest  from  the  early  and  persistent  symptoms  of  dro[)sy 
associated  with  disease  of  the  kidneys.  The  autopsy  showed  extensive 
disease  in  both  lungs  and  large  amyloid  kidneys.  The  liver  was  a  little 
enlarged  and  on  section  })resented  very  many  small  abscesses,  none 
larger  than  a  marble,  containing  a  creamy,  in  places,  bile-stained  pus. 
They  could  not  be  traced  in  connection  with  the  portal  vein,  the  branches 
of  which  were  free.  There  were  a  few  ulcers  in  the  lower  part  of  the 
ileum.  The  mesenteric  veins  were  not  involved  ;  no  inflammation  about 
appendix  or  pelvis.  December  0,  18SG. 


Two  cases  of  cancer  of  the  stomach. 


Ajn->l,  imi    Fu.nilv  and  .u.-son  .  '  U,.ivc>rsity  Hospital  in 

-••ko<l  fulness  i„  „„;,„;,,,  ^H^^Z^!;'''^    ^  '''"r^'  '''"'"'-"'  -'h 

ep.^astncMx>,nc,„exte„clin,-tothV  .  e  "i  "'  "  ''""'  ^'"'"'^  ^"'nor  in 
«^  ^i'o  ."ass  was  about  anin.  a,!:  ,:,"';'•'''' "''^  "-''''-•■  Tl.ooentre 
1-cns.on  linn,  tln-oo  inches  in  L^  '  "1"^  '"  '""■''  ""''  ^^  ''''d  a 
f'"""^  tl,e  .toniach.     The  live,-  ''^'''•Mvas  n.o.lenitc  dilata- 

-■•'-!^-  "--^ained  in  ti^  :;,£:;;:;  ;"^^  '""--  c^ans  ..:! 
-n.tn,,.  was  very  troubleson.e,  I,  o^^^^  ^-n-  months.  At  first  the 
^'■-luent.     The  vonn-ted  n.atter  el .1  ""'  "  ''^■^•'""^'  »'"^'l'  iess 

the  .surcina  ventrienli      D„  t        '  "'  "^  "»  -^traonlina.-y  nunU.er  oJ 

---     He  enn.ciate.,  .api,,;;^.     ^  S  ^ly'^f'"'  '''  '^^^^^^  -« 

ilie  stoniaei,  was  ]ar<re  •„  d  th.         ."'"'^^  "'August. 
-"CO.  of  the  anteno.  w^  1  ^^  nir"  ^'"^""  ''  ''^^^^  ^'^--tin, 

Lore  Mere  several  soft  slon-d.  .nd  ''''''' '^''"^"^^  i-  the  pvlorus 
^^•'«^  ^i-  --"fiUmted  thiekeneS  w'a  1 .  1  "  ' '^'' ''"  "^^''^^  "^"  ^'^  '"••'- 
^vere  no  secondary  n.asses  in  the  or™    ''"'"""'"  "'^J^^''"'""^'^-     There 

^'^^'^^-^''nnlar  cancer  of  ny/C''    ,     t. 

P;^-tofDr.J3olling,wass;ntM~^'-s^'=?;   f^"^    ''    ^--. 
nearly  a  year  with   dvspeptic  svn,  '      ,  ^^'^  ^'^'^  ''^e"   i"  for 

i;ad  '--' considerable  jii^^j;^^;!"!  ^"^  ^^'^"^  '-alth,  and  the^ 
At  the  first  visit  the  .no  •    r^^!:  ^  ^'>  ^'^  "^ture  of  his  ilh.:^ 

-"'very  nKKlerate  wasting.     u'r^'^T ''"''  'r'  '""^''""•'  -'-"-^. 

TJ.0  genera]  and  local  svmpton  s  v  /  ^  ^''*  "^^^  *'^'^!'-'- ^^ '>-lilated. 
:;'T"  f^'"-"f  ^'•-to.nal.h  iZr,,  ;r'^'':,^"«^-"t  to  indicate 
t'-/a.^t  the  small  mass  in  the  epi-  ns  1  "•""  '^'''^  '"-^---«  and  on 
-'the  eon-lition  had  in.prove    l^l^t  J'^"  ^;'f  ^^'"  '"«-  distinct. 


"'ore  of  the  case  for  fb, 
pi'esent   at    the 


somewhat.     Idid 


not  h 


-  -"ths,  when  Dr.  iiolling  ask 


l--t-nc   at    tlie  autopsy.      TJie  .(>,.     7  ' 

pronounced  and  thf^  LL  •  ,         *^»"'aoh  symptoms 
'  the  emaciatioii  extreme.    Tiie  disea 


lear  anything 
ig  asked  nic  to  be 
liad    become  more 
ise  was  found  limited 


p.  Off. 

) 

f  : 


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iiJI 


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. 

i'^ 

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to  the  stomach,  in  I  lie  pyloric  region.  The  sections  lioro  shown  iliiistrivte 
its  characters.  The  i)yh)rns  was  involved  with  the  (liiodenuin  for  an 
inch,  and  the  stomach  for  at  least  two  inches,  forming  a  uniform  annular 
mass.  The  little  finger  could  he  passed  into  the  pylorus,  but,  as  the  sec- 
tions show,  the  lumen  was  much  narrowed  by  the  projection  of  irregular 
masses,  which  gave  ii  sinuous  outline  to  the  cross  sections. 

December  \},  IS.m. 


Henna  of  em-ton  and  appendix ;  perforation,  of  liitter ;  old  peritijp/ditio 
ahseeM;  recent  larger  one;  (jeneral  peritonitis. 

C.  J.,  tot.  50  years ;  cook.  Admitted  to  University  Hospital,  March 
4,  1887.  ' 

On  Sunday  niglit,  February  27th,  after  having  taken  a  walk,  was 
suddenly  seized  with  intense  i)ain  in  the  hypogastric  region.  Immediately 
took  to  his  bed,  vomited  two  or  three  times,  and  on  the  following  day 
noticed  that  his  abdomen  began  to  swell.  On  Wednesday  night  Imd 
forty  stools.  Dr.  Wharton  gave  him  a  hypodermic  of  morphine,  which 
relieved  the  i)ain  for  that  night.  On  Friday  was  admitted  to  hospital. 
Abdomen  greatly  distended  and  tympanitic.  Breathing  rajjid  and  difh- 
cult.  Pulse  112.  Complained  of  great  pain,  chiefly  in  hypogastric 
region.  Temperature  100''.  Was  given  enemas  of  turpentine  with  sweet 
oil  ;  whiskey  every  two  hours ;  poultice  over  abdomen. 

March  o.  Dr  Wharton  gave  history  of  the  existence  of  right  inguinal 
hernia.  Temp,  to-day,  99^  J'eels  much  relieved,  but  still  comphuns 
of  j)ain  and  difliculty  in  breathing.  Vomited  this  morning  twice;  dark- 
green  in  color,  but  no  fecal  odor.     Bowels  have  not  been  opened. 

(Uh.  Complains  this  morning  of  intense  ])ain.  Is  vomiting  constantlv. 
Was  given  a  lialf  grain  of  morphine  in  two  hours,  which  relieved  him 
for  a  short  time.  Iloirmann's  anodyne  and  rectal  tube  gave  no  result  in 
relieving  tymimnites.  Punctured  three  times  witliout  relief  Died  that 
night  at  1 1  p.  ^r. 

^HCo/wy.— Well-built  man  ;  abdomen  distended.  In  nipple  line  !iot 
more  than  two  finger's-breadth  of  liver  dulness.  Three  punctures  of  ab- 
dominal wall,  (me  in  right  lumbar  region  and  two  in  epigastric.  On 
opening  peritcmeum  gas  escaped;  moderate  amount  of  fluid,  chiefly  in 
flakes,  sero-purulent.  Coils  of  small  intestine  greatly  distended,  "one 
crossing  at  the  level  of  navel  as  large  as  arm  above  wrist;  toward  pelvis 
not  so  large.    The  general  surface  of  intestines  was  injected.    Peritoneum 


n 

coated   in  j)lacos  witli    recent    lv>,.nl,      .<  i 

"'"'  '"'^"'"mg  colon  containe(   eon«iV(>nt  fof.na  fi.       •    !■ 
verv  dry.     Ciucuni  wi^  ..,ll„...     .  .      i     .,""•"'"  ""^  "'f^'s.  tlio.so  in  former 

P.."I.V  fcn„c,l  by  fold,  of    ,;  ,;  :?"■■■  «"™"f  ■■"«»l.  -'I  >™lls 

P""d,.      I! ,,;  contract    IP  ■„       ""'",'  """'"'"''  """  """"1»»'' 

.«.t,„„„,,c„c,l,  nope      «„",,''";'';'"«-'•      ««"-»"'   ll.-„-c  „„.l 

inci,«  of  .fe,,,„id  ,,i„o  ;■':;::;:  r,:;s  "■- «-"';''j>y  ■- 

I«a.l.K  the  |,r„.,i„,„l  orifice  «■„.,  fi.nn.l  .„  ,  »«;'''""g  *»r  ap. 

into  ab,lo,„c„  innood         .  I      '  ;,l  '  T      "'"'"  "-"■•"•  I'"*'"'  ■""■'l' 

;;...ot,,„,o,ut.,.,„d::c'L:;l;;;::,;T:;;i;rr^^ 

^rec ;  terminal  tliree-(,uarters  of  .„;  •  ,     '^      ,     '' "      ^'"^  ^"'"''"  ^^"^ 

cii-otly  into  a  sn^nller  dr  ums    il       "         l"^-'  ''"'»'""»'  '""'  '•l-"'->d 

one.  Ti.e  ^^oundaries  i;  ^  :;,^;t.  •;::::: r'^''  f r^'>'  -^"  '^^>^- 

^'^'"'»  "'  ^ro"t,  sign,oid  flexure  nndei        .        T      '  '""'^"^^''^  '-^"^^ 
^vas  along  tl>e.i.nu>i<lfle"ri.,'         'f  ^"'^^^"'""'^"J  f'-^^-^s  behind.     It 

'S>/...  large  1^1^  "'"^  ^'"^  abscess  passed  into  Douglass  pouch. 

Klihunj.'^  somewhat  swollen. 

Ihin-t  valves  normal. 

Lnng.i  normal. 

tion  of  the  ap„e,„l  V      ■ '  r  ?"l>I>'"-"«'».  the  rcM.lt  of  porfin,,. 

e«.>.od  f  ,r  »,ne  ti,n     .', ,  I  n  ,  "'T'"'"  ">"■""'•  '""'  '''""'"■^- 

sya.„ton„.     The  fr   ,',        ,        h     hM  '"  '';.'";""^'.'""- «oUed  serio,,, 

a".i i. took  both ,■:;  X :  ,  ,r '  m   °"""  "•■■•  "'""■""■ 

the  parts.  ""  °"'  "'"  V"""'  «lalionshij,  of 


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12 

The  fact  tlmt  he  hail  an  old  hernia,  which  Dr.  Wharton  had  at  one 
tinio  reduced,  siijrgested  the  pos^sihility  of  the  troidjie  oriirinatiiii!;  about 
it.  J^uparotoniy  was  advifcnl,  and  Dr.  Ashhiir.st  eanie  out  one  evenini; 
for  the  purpose,  but  the  patient  refused  his  consent. 

Februanj  2-i,]SH7. 


ilii 


•     Pi/o-pneumo-fhcmtx  mbphrenicus. 

W.  S.,  £et.  24  years,  was  admitted  to  the  surgical  wards  of  the  University 
Hospital  on  November  l-'j,  1885,  having  fallen  under  the  wheels  of  an 
engine.    The  left  arm  wascrusiied  and  he  had  a  deep  scalp  wound.    The 
arm  was  amputated  at  the  upper  third.     For  a  week  he  had  lu-ematuria 
and  he  comphiined  of  a  pain  in  his  left  side.     Subsecjuently  erysipelas 
developed  in  both  arm  and  face.     About  three  weeks  after  admission, 
signs  of  inflammation  appeared  in  the  left  infra-scapular  region,  indicated 
by  a  rise  of  temperature,  dulness  and  feeble,  blowing  breathing,  and  he 
was  transferred  to  the   medical   ward.      The  stump   at   this   time   had 
almost  healed.     Ivxamination  of  the  chest  revealed  circumscribed  dul- 
ness at  the  left   base,  extending  nearly  as  high  as   the  angle  of  the 
scapula,  and,  laterally,  to  the  midaxillary  line.     Tactile  fremitus  was 
diminished;  on  auscultation,  feeble,  blowing  breathing,   and   on  deep 
inspiration   rales.      Slight  cough,  very  little  expectoration.      A  se])tic 
pleurisy  was  susfjccted.     The  condition  remained  practically  unchanged 
for  several  weeks,  during  wliich  there  was  irregular  septic  fever.      He 
complained  at  times  of  pain  in  the  ilium  and  left  side,  particularly  when 
he  drew  a  deep  breath.     He  soon  began  to  spit  up  fetid  pus,  and  in 
twenty-four  liours  brought  up  several  ounces.     It  was  concluded  that  a 
localized  em|)yema  had  perforated  the  lung.     On  examination,  tympan- 
itic resonance,  amphoric  breathing,  and  metallic  rales   were   found  low 
down  in  the  postero-latcral  region,  beneath  the  ninth,  tenth,  and  eleventh 
ribs,  indicating  pnenmo-thorax. 

The  autopsy  showed  the  existence  of  a  large  abscess  behind  the  left 
kidn'v  and  descending  colon,  extending  from  the  diaphragm  to  the 
crest  of  the  ilium.  The  chief  part  of  the  abscess  lay  above  tiie  kidnov, 
beneath  the  ribs,  and  in  this  region  there  was  a  distinct  cavity,  part inliy 
occupied  by  dirty-brown  pus,  siuiilar  to  that  which  the  patient  had  ex- 
pectorated during  the  last  two  days  of  his  life.  Part  of  the  diaphragm 
was  in  a  sloughy  condition,  and  two  orifices,  through  each  of  which  the, 
point  of  the  index  finger  could  be  pjissed,  communicated  directly  with  an 
abscess  cavity  in  the  lower  lobe  of  the  left  lung.     The  pleural  membrane 


of  this  part  wero  I'rciitlv  fl,;,.!.,..,    i         i    , 

'^t  i''^  "Pper  part  a  .li.tinct"cicmid      Lt  I'T  U  "'  """'  ""'  '•'•*'^^'"^'^'^ 
tissues  were  strongly  ndhJuL  "  '"'''"^^  ""^'  '^<'j"-^-'»t 

The  seqiioiice  of  evi'iif^^  in  fi,;. 
or  ki.l„oy  with  hruiJ  ^      hI^^  Z^T  "^'^'^:^'"^''  "^  ^'^"'>-  ^   ^V"u„d 

'-•^^>-'i'-'5-^ii'  ^h.^^^^^^^  -U,,oitywith  ..bphreni.  al.co.  i 

of  a  subphrenic  aiUomain    .  '    ^^   ^  f     "'"^  ^1"  '"'^  '  ''-^'"P-.t 
^.^P^ets  orthc  le.  side,  the  .^l^pll'ltSir  '''  ''''''  "'''  ^"^^^ 

..e;^r:;ih  :rZ:r.sr:r:r''"'-- '- '-  -  - 

i"  ^irc/ur  der  HeUhnulc  for  187  '  "^^         '"''  ''  ""'""'  '"'^  '^'"^"<^'-. 

one,  followin.  injury.  The  liter  Unr'T'H'  '"''  ™''''  ""'  ""'"^'^  ^""'^ 
occrri,.,  with  linlyphlit'  ^g  :  '  ^Dr  V'f  ''^  ''^^"'-'^  "^=^  ^'- 
Canada  J/.  J/../  ,„/  ^s'..^/.;/  j!^Z    '  "'"f'  '"  ^"^^  '''■  ''  *''^ 

•  -^"""ar?/ 28,  1886. 

A  <-a.e  of  retroperitoneal  ^^i^dle-eeiU  sareor.a  .Uk  e.ten,re  tkro.,,ie 
^nd  hemorrhagic  changes.  ^omuofic 

In  addition  to  features  of  general  pIIm;,..,!  •  . 
is  worthy  of  record  fron,  the  r  r   v \v  T"""''  '^''  ^""""■'".'?  ^"^« 

ronn  large  ulKlonnnal  t„lr  2  i  nl  "'^'r'""''^' ^'"•^•"'-^^- 
hemorrhagic  destruction  which  "^  ^2^1  Z  '"';'  f"  '"^"''^'•'-•^'^ 
undergone.  ^''-*'^'^'   I^'*^'^'""  o^  t'le  growth  had 

-th  a  tu„,or  of  abdon/en      H  d       "  '"';^'    ■'^^^'^'"'^^^-  2'^'  1884, 

tohacco  to  excess.  Had  b  en  tit"  "  '"'7^'^  ^'''^'''  ''^^  "-'^ 
ill"e,«s.  Fannly  history  good  W  '  'T'"';  "f'  ''  '^''^  "  ""^'^  P'-^'«^"t 
-nths  ago  he  notic.l  1,!'!;  d  """  "''''  ''''''''''■  ^^'-'^  -•- 
inconvenience,  and  it  wa  "ot  ,  t""  "r.'  ""''''''  '''^''  ^"^  ^""'^  - 
uncon,fortable  after  oatin"!  .  ""T^'V'T  '''''  '"  '^»''^"  ^'^  ^^^ 
iost  about  eighteen  poundJ' ii;  we  g  "  H  ri^el^'  ^'•^"^'"  ''-' 
ravenous,  -mhI  the  thirst  excessive     "  /'"/ ^  '"'  '^^  *""^'^'  l^''"» 


'  i 

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14 

clean  ;  a|)potito  good,  but  ho  ciiiinot  take  large  meals  on  ac-eonnt  of  sen- 
sation of  iiihios.s.     Says  he  is  in  good  health,  only  weak.     Passes  about 
seven  pints  of  palo  urine  of  a  specific  i^ravity  of  about   1004,  with  a 
trace  of  albuiuen;  no  casts,  no  sugar.     Exauiiuation  of  thoracic  or^^aiis 
negative.    Abdomen  presents  a  symmetrical  prominenco  in  the  neighbor- 
hood of  the  umbilicus,  rather  wide  and  Hat.     Superficial  veins  not  dis- 
tended.    On  palpation  a  solid  tumor  is  felt,  occupying  the  hypogastric 
and  umbilical  regions,  aiul  extending  laterally  into  the  Hanks.     It  is 
irregularly  nodular  on  the  surface,  slightly  movable,  and  the  n)unded  out- 
lines above  and  laterally  can  be  distinctly  felt.    Eelow,  the  outline  is  not 
clear  and  cannot  be  defined,    ({rasped  firmly,  it  can  be  moved  as  a  solid 
uniform  mass,  occujiyiug  a  median  position.     Xo  one  part  is  softer  than 
another,  and  there  is  no  sense  of  tluctuation.     Percussion  gives  a  dull 
note  over  the  tumor,  tymi)anitic  above  in   the  e])igastric  regi(Mi  and  in 
the  lateral  part  of  the  und)ilical.     From  splc(>n  and  liver  the  nuiss  can 
be  easily  separated  both  by  percussion  and  palpation.     There  is  no  pain 
in  handling.     Measurement  round  umbilicus  thirty  and  three-quarters 
inches.     Glands  in  groin  not  enlarged,  feet  not  swollen. 

He  stayed  in  hospital  until  Novendier  11th,  the  condition  remaining 
unchanged,  except  that  he  gained  three  or  lour  pounds  in  weight,  and 
his  general  health  had  improved.  The  condition  of  the  urine  was  oj' 
interest :  ibr  several  weeks  he  continued  to  pass  more  than  seven  pints 
daily  of  i)ale  urine  of  a  low  specific  gravity,  with  a  trace  of  albumen, 
but  in  the  last  three  weeks  in  hospital  the  amount  fell  to  about  three  and 
a  half  iiints.  On  October  18th  he  was  made  the  subject  of  a  clinic, 
when  the  diagnosis  of  Lobstein's  retroperitoneal  sarcoma  was  made.  The 
l)olyuria  was  attributed  to  irritation  of  the  renal  nerves  caused  by  the 
pressure  of  the  tumor. 

On  the  loth  of  November  he  went  home.  Subsetiuently  he  was 
admitted  to  St.  Mary's  Hospital,  under  Dr.  O'Hara,  and  the  upper  \x\xl 
of  the  mass,  which  had  become  soft,  was  aspirated  by  Dr.  Moars,  and  a 
couple  of  ([uarts  of  bloody  fluid  removed.  lie  was  taken  to  his  home, 
where  he  died  in  April,  and  I  have  to  thank  Dr.  Miller,  under  whose 
care  he  was,  for  an  invitation  to  be  present  at  tiie  autoi)sy,  and  for  per- 
mission to  utilize  the  specimens. 

Ai(fo/).-<ij,  with  Drs.  Mears  and  Miller.  Considerable  emaciation; 
abdomen  distended,  discolored  in  upper  part.  A  solid  1  imor  could  be 
felt  occupying  a  large  part  of  the  cavity,  firm  below  and  soft  above.  On 
exposing  the  peritoneum  a  large  mass  occupied  the  lower  three-fourths  of 
the  cavity,  pushing  up  the  intestines.  The  membrane  was  smooth,  in 
places  covered  with  small  grayish-white  nodules,  and  iu  the  Hanks  there 


15 

wore  a  few  adlicsioni      \t  t\,,.  t        c  .t 

co,„,c,l„vc.,.,l,c..„  fnc^,!l'     °  "I'!'""".,....     JI„„y  lar«„    voina 

'|""%-|.  .i.ic-i,  i,i.„„i  „„„„,  ,    i  '    '"":''  I"'"'"" ""» ""  ".iiico, 

ab......  two  pi„„  ,„•  „„i,,  ,,f\:,,t  ,„':::'''''  ;■'"■''>•  ".'«'■" «»- 

(•arefiilly  removed-  tlioro  u-„u      i    li      '^'""'^•'^'-      ^'"-'  I'ltostincH  were 

;-l  into  the  Icavh-'m ',:':;:   ^a  ^'^  '''^''''\  ^"""""• 
1""'  "oadl.csions.     Jk.|ow -.nd  t.  V  '■'"'•'"''  ^he  tumor 

>"•■•...  <'f  tho  pelvis    r/eio  V    ■    "  ''"^'^  """^■l'"H.,t  was  to  the 

I«-tion;  tho  t  p   3  H         d  li^l      ;     "■   ^""""^   ""^   '"^^"■••-'  i" 
tl.c  tumor.    Tl.oadu  iZ     hi,         ,\T'»   '"'^^'^"^  the  syn.physi.s  and 

we^i.  was  estimated  a;:c:x;:fpL:;r'^"'-^''^'''^^^      ^''- 
a  iow:;:;Hi:;r  t!.:^  :;;:;.:;:';^' ""  t"  -'''-'  '-'^'  ^'-^"-  -^^ 

pint  an<l  a  half  of  b  ^ ti   h,'^?'  ^'T'"  ^"^'  "^•'^"''  '"«-  ^''->  ^ 

which  also  ]ine,l  the  wa     .  ii   '  "' "^  VcnowLsh-hrowu  n.atorial, 

-ovedattheta,pi„:h;;d'::ii:;ur::ri;'::^ 

by  cxtrava.ated  bio       o  -^  !^  , '        '  "  '!'^''  "'"^  everywhere  surrounded 
i"  son.e  plaees  ex^o^u;.  7  '  P'-t.onjust  within  tho  eapsule,  and 

nothin.   n^-^estive         •;  "  ""!"''''•     ^"  ''""=*  ■^^•^•^'""  ^hero  was 

-ten^s  o^^n  :;m  1::^:^:;;  ;-xr"''^''' .''^ 

tiwi  of  tlio  luivc-  „.„-l  .,(•  ,1  '^  "  ""'  ""  Ini'iiii-itiou.     Scc- 

*".iy  of.  i.c„,„„eo:r:,:t  a "  ;::'z ;;;.,;;;.  ""'■™™—<'  -i. 

«m(  l«n-t  of  11,0  ontiro  nms,  '  '        "™''  "  '■"■''■■'•  "'»«"'«• 


a. 


'^l. 


s 

i 


l:'(, 


) 
r 
> 
) 
1 
'  k' 
0 


in 

tieiiliirly  llic  rif,'lit ;  dno,  doiihtloss,  to  pivsaure.  Tli(«  Ii.«urt  sliowcd 
niodcintt!  liyiHM-trophy  of  tlu!  lott  vt'iUriflc.  Aurtii  sukioiIi.  Lmi^s 
iiuu'li  ciirlxiiiizoil,  and  Hoiiu'wliat  (•mphyscniatoiis.  IJraiii  not  cxainiiied. 
lfinfo/i)f/lriil  iwiinlifflion:  TcaHcd  portions  sliowod  that  I)otli  |)riniarv 
and  secondary  growths  wtTo  conijjosod  of  l;ir;:,'o  spindle  cells,  closely 
packed  toK,.tiier.  'Plio  reninantH  of  the  original  growth  .situated  at  the 
lower  part  of  tlui  tumor  were  (jiiite  distinctive,  and  hail  not  undergone 
degeneration.  There  were  also,  in  .some  places,  portions  of  sarcomatous 
tissue  just  within  the  capsule,  separated  from  the  central  dry  thiomhus 
by  freshly  cxtravasaled  blood,  Sections  of  hardened  portions  showed  a 
typical  spindle-celled  growth.  The  thi'ondnis  presented  a  finely  granular 
basis-substance,  between  .strands  of  translucent,  hyaline  m.itcrial.  All 
traces  of  cell  structure  wore  gone. 

JieiiKid-K.—Thu  points  of  interest  about  this  case  nuiy  be  brielly  eon- 
sidered  under  the  following  heads. 

T/ie  r/Kinirfcrof  t/ir  f/roirt/i :  Sjiiudle-celled  sarcomata  rarely  form  huye 
abdominal  tunuirs.  In  the  examination  of  a  considerable  nund)er  of 
new  growths  of  all  sorts,  removed  from  the  peritoneal  cavity,  I  have  not 
met  with  a  similar  one. 

T/ir  ^itmilloii  of  oi-iijiii  was  unusual.  1  fully  anticipated  that  wc  should 
find  it  springing  from  the  Iund)ar  retro])eritoneum,  the  common  i)oinl  of 
origin  for  large  abdominal  sarconuita.  Here  the  growth  seems  to  have 
begun  in  the  subserous  connective  tissue  in  front  of  the  symphysis,  not, 
from  the  peritoneum,  for  it  was  ipiile  loo.sely  attached.  Jt  is  interesting 
to  note  that  spindle  celled  sarcoma  not  infrequently  originates  in  the 
connective  tissue  of  .'-icari)a's  space,  a  tissue  directly  continuous  with  tliat 
from  which  the  tumor  in  question  grew. 

The  looseness  of  the  attachment  and  the  readir'..--;  v"';  Inch  the 
tumor  could  be  lifted  out  of  the  abdominal  cavity,  made  us  rcirret  that 
we  had  not  yielded  to  the  patient's  urgent  solicitation  to  have  the  abdo. 
men  opened. 

The  charudrr  of  the  rrr)rcs.->ive  rJunxjrs:  So  soon  as  a  tumor  obtains  any 
•fo  expect  to  find  in  it  areas  «)f  degeneration,  fatty,  caseous,  or  cuh  a- 
re  >,.  ,  V.  .  if  '•  apidly  growing  neoplasm,  hemorrhages.  Sarconuita  . 'ire 
pa  it-.-,  'a'-'y  prone  to  hemorrhage;  indeed,  when  growing  actively,  it  is 
i<>.n:r...  CO  find  foci  i  extravasation  in  them.  The  effu.sod  blood  not 
unfrequciitly  becomes  encysted,  and  the  dark  contents  appear  to  result 
from  the  liipiefaction  of  the  coagulum.  In  a  large  tumor  several  su(;h 
cy.'-.ts  may  exist.  Snudl  scattered  hemorrhages  are  more  common,  and 
the  blood  gradually  undergoes  changes  without  materially  altering  the 
appearance  of  the  growth. 


«i» 


17 

I  ho  coiKJitioii  ill  (I.  1 

^^•'"''  "  c.o...si,loral,lo  portion  w,.;  ;    ,  '""  ",  :'''>;  ''"•'•'  ^'"•■""'n... 

"•"""•'•'"f  ^'  ^'-'-..ion  or  a     :. ": '  'rf  •  ''■"'■  ^---i 

.een   prolon^cl,  tl.o    l.loo.I   llnj]l  't,  I'.V  »«P'niHon.     Ha.     life 

l->.no  inspi.atc<i  bv  tl.o  a  '  ;.  ^ ':r  T  ""'";'•.:'-'"'-.  i'-e 
'•o'"»..nlor  l.avo   I.oen  oonvc-tod  in  o  i     .        T"  ^'"''' I'"'-t«. '".<!  r|,e 

o-«te.I  at  tl.o  lower  part  of  ^  ^^      '"'''  "  ''"''''  ''''^  '--  - 

"''  *'-  «"".  1-nl  thron.bu.  win-  ',,    /T"'''  '---"''o  to  infer 

'-  ent.ro  fuaor,  was  forn.o,!  in  ,|  L      "        p  '  7r  *'"^"  «"^-^"^'^'  '^ 

'-"^th  tho  oapsnU,  whid.  were  ^'"  r^;,/  "T^,  ''"'  '-»"n-ha,e. 

"";^-'  ;onl,|  a  di.i„.t  l-uninatio^^  ;;"'^''  ^^^  1"—-  though 

Pl-us  or  npon  the  m:;!  .llr  X;!:  '»  "-•"•'"n.en  npo„  tho  solar 
rtow  of  nrine.     The  irritatio  ,  i,  '/     '  ''  "'"'■>'  -''^"''^  ''"^•'■^•a^^o  in  ,he 

^1'  to  nonnal  ,.f,re  uXZ^^l^T  W  T"'''''  "^  ^'^  ''"'-- 
ci.se  con,lition,s  under  which  thi.ocZ  r  '^"  ""^  ^^*'  '^"""-  ^''o  ,„e- 
need  carefi.l  observations  o  '^^^^f    r'""^  ^^  '^  "^  --•  -'<i  - 

I  -us  was  foun,,.    Owin,  to  ,h        f'^^f^'  !'^=--'-'^tion  of  the  solar 
ti'o  post-n.orten.  exanu-nation  J's      '.f  ^""•^'""^^''''^-^'^  ""der  which 

^•ot'ld  he  nnt,Ie  in  this  case  """■"''^•''  ""  ^''«^<^'''fi'>"  '>i'  the  nerves 

^•f  J; 'i  ^"iijd  t^^ir  :c::;  :r  ^-  ^ — .  -ou,h 

I^'--  Tyson  wo;,|<|  Uk,  ,,,  ,,,,^  ^';' f'    ^^'t''  «on,e  hen.orrha^e. 

^'•^^^tof;  thron.bo.icde,ene;      ,^;.r;V;'f '."Vt  ""'"'-•  "^  ^he 
"".''.••'^■="">  in  it  possible  for  clots  t     t  Tf  ^''"'"-""^-^  "^  ^""'o^-s. 

-^;'>uItun.o,  as  is  assorted  bvU;,';  '"""■^^'  '"^^'  ^'^  ^'-'-f  thj 
i'le  1  resident  remarked  th-if  flw, 

:'",""'■  t""''"™'.  i"  view   ,',:;:„;;•"  °'; "■'■'•''  '"-est  «,,„» 

""    "*"1  Dr.  0,1c.,.  „.|,c.l,e,.  the     ,,1''  ',    "';='"''  "■•«'*'-o..cc. 


> 

r 
) 

I 

i 

c 


ii 


i..'i 

^  .( 

li  1 

( 

! 

if  .}■! 


Ij  m 


18 

from  a  similar  growth  occupying  the  more  usual  position  in  the  lumbar 
region. 

Dr.  'l\son,  in  connection  with  the  clinical  history,  called  attention  to 
a  retroperitoneal  sarcoma,  ])resente(l  by  him  to  the  Society  last  winter, 
which  had  been  mistaken  by  liim  and  others  for  a  tumor  of  the  kidney. 

Dr.  Osier,  in  re|ily  to  Dr.  Tyson's  first  (juestion,  stated  that  the  only 
remnants  of  sarcomatous  tissue  were  two  or  three  small,  but  very  dis- 
tinct, portions  of  the  lower  attached  part  of  the  tumor;  the  remainder 
had  wholly  undergone  this  throml)otic  cliange,  and  in  tlie  upper  part  had 
become  converted  into  a  blood  cyst.     This  change  was,  no  doubt,  slow, 
with  first  a  destruction  of  the  sarcomatous  elements  by  the  blood-clot, 
and  then  a  slow  process  of  necrosis.     There  was  no  evidence  in  any  part 
of  the  tumor  of  an  invasion  of  tlie  coagulum  by  the  sarcomatous  ele- 
ments, as  is  not  infrequent  in  thrombi  in  other  regions,  as  he  had  seen  in 
the  portal  and  renal  veins.     The  chief  interest  in  the  specimen  lies  in 
the  remarkable  extent  of  the  thrombotic  change.    Looking  at  the  clinical 
aspect,  he  had  diagnosed   the  case  as  one  of  retroi)eritoneal  sarcoma 
from  its  large  size,  the  central  position,  the  slight  movability,  the  dis- 
tinct separation  from  liver,  kidney,  and  spleen,  not  being  placed  more 
on  one  side  than  on  the  other,  and  from  the  fact  that  palpation  in  the 
lumbar  region  gave  no  pain  or  other  evidence  of  kidney  lesion.     It  was 
firmer  above  the  brim  of  the  pelvis  than  any  other  tumor  he  had  ever 
examined.     One  remarkable  feature  about  these  tumors  is  their  painless 
character;  this  jiatient  complained  of  no  pain,  and  in  two  other  similar 
growths,  which  he  described  at  length,  pain  was  not  a  symptom. 

Jdiiuarij  14,  1886. 


(Jirrlio.-ii.'i  of  liver  ;  ftital  hrmorvhagc  from  m-iopharjeal  wirix. 

David  M.,  set.  44  years,  white,  admitted  to  Philadelphia  Hospital 
Surgical  Wards  .,n  October  *2(i,  1886,  with  an  ulcer  of  the  leg.  Had 
been  a  hard  drinker,  but  up  to  the  jjresent  time  had  not  been  unwell  for 
many  years.  He  had  had  syj)hilis.  Patient  was  very  pale  and  trenui- 
lous.  On  the  morning  of  the  27th  he  complained  of  nausea,  and  at  1 
o'clock  P.M.  vomited  a  large  quantity  of  blood.  Tlie  vomiting  continued 
at  intervals  through  the  afternoon  and  night,  and  he  lost  .several  pounds 
of  blood.  I  saw  him  for  the  first  time  at  noon  on  the  'ISth,  when  lie 
was  in  a  semicomatose  state,  could  not  be  moved,  was  breathing  deeply, 
and  was  evidently  failing  fast.  The  examination  of  the  thoracic  viscera 
was  negative.    In  the  abdomen  there  was  notable  diminution  in  the  area 


19 

:?  lir;™,',;;:::;;:"  -rMrf  *:ri  T-r -r  ,"■»'  "-^^  --  «■«  '-- 

ke|..,  u„.l  „»  tUcldv  c  ,«  ;,  '■?  '""'  '""»  ™'""«l.  '""I  been 

.tool,  wi,ic.h  i,t  i>J,e  0 ^u  . ;.  ;r  r""",""'  ""•■' "'''""  ''"'"«'■•  a 

contracted.     The  diu  ,l,r,.ni,.it;.  "'»''"  '''''«  ^■^■'■^'  '»"«'> 

covered  the  kidneys,  and  the  no      J  1  ,         '''  ""^"'"''^  "^'  ^'^'^^els 

did  not  contain  hLd  :  ^  :  ;! ^le  ■ ""  '"  ^"'""-  ^'^^  ^^"-^^ 
tl.o  canliac  en<I  were  great  "il,"."' '  "?  ''"'''"'■  '^'^  -'-  "'-ut 
it«  lower  half  a  network  i^  i^  f-  ''"^  "^"i''''^»"'^  P--"te<l  in 
ti-  mucosa.  One  of  thL  t  s^  i'"'  "-7  "'  "'"'^  ''''"J^^^-^  - 
-anner  along  the  posterio  mv  ,  ;  at  it'^  '  '  "'''^"'"'  "'  "  ^"'•^"-•- 
elevated  spot,  covered  wi,h  a  i;,  b^  T  • '""  '"''V^'""-^"*'  ''  ^^''^'i^h 
on  the  vein,  and  a  probe   n      '  ,     .       ^'""''"'^  '"  ^'  ^''  ^•'"^''on 

onfice.     This,  donhtles        Jt t   1,        J    "',"  '"  ^"'"^  ^''^^'^^^  *'- 

i?c.ma.Zx-BIoedi„<:w  nn  ''''  I'«>»orrhage. 

ni^od  event  in  .i::!^!7Z  Z"T  'T  '  ^  '■^^^'  ^"^  ^^^  --^- 
f>n'l  the  veins  of  the  gnlJet  .n-ontlv  r  ,  \  ■""  "'""''  ""common  to 
anastomosis  with  the  ^/^X  ''"'"'  '"  '''''  ^''^^-«' -  their 
portant  channel  by  which  t  e  '  L  I'T'  ?''''''^  '^^'"^''^  ""^'  ""- 
l=>tion.  In  cases  oVfata  Le  nt  i  '""^T-"'"  ^'"  ^""^^^•''^'  -"-- 
agus  should  always  be  nu^^  h"  wi^    H^^ 

I>e  overlooked.  '       "  " ""  ^''^  "'^"^^  «f  the  bleeding  may 

I'^chruary  24.  18(S7. 


i";  I 


i      i.i 


f:.  > 

i    r 

) 

::':        ■ 

1 

■s ' 

p 

1 

r-  ■ 

,1 

1 

Aneurisms  of  the  branches  of  the  circle  of  \V\m-     i 
part  ...   the   historv  of  cerebral   hon,  ,      ''"''^  ''"  nnportant 

anouris„,s  of  the  nutritive t'l^"^'"^^'  ""^'"»  "^t  to  n.iliary 
tl'an  the  state.nents  of  text-bool-s  w  17-  'T'  '"■"""'^''  '"'"'«  ^'^"""on 
'li-ction   is  n.ade  the     a  •      ^^  unless  a  careful 

two...  cases  are  .,,J.^:.:X;.^^Xl7::^';  "^'"'^^^  «^ 
iIosi..tal,Mont.-eal.     !„  oi.rht  th.  "nn       •  ff    '''*^  ''^  "'^'  ^«"oral 

l-nor,.hage  ;  in  fl.„r.  th  ^"^  '  ""r  '"'"?  "^^  ^"^^  -^'  -"-1  fatal 
'l""ed  any  syn.pton.s.        '  ""'  ^'^^''"'^''tally,  and  had  not  pro- 


'% 


U   ' 


20 

A  majority  of  the  patients  were  youiii,'  or  middle-aged  individuals. 
One  was  a  child  of  6,  another  a  lad  of  17,  and  a  third  a  man  of  20. 
In  live  the  age  was  about  40.  The  early  age  at  which  they  occur 
has  been  noted  by  several  writei-s.  Thus,  of  seventy-nine  cases  collected 
by  Coats,'  there  were  forty-two  between  the  ages  of  10  and  40.  The 
case  here  re[)ortcd,  occurring  in  a  boy  of  G,  is  the  youngest  of  which  I 
can  find  any  note.  Eight  were  males  and  four  females.  The  arteries 
involved  were:  Left  internal  carotid.  Case  I.  ;  right  Svlvian,  Cases  II. 
and  V. ;  left  Sylvian,  Cases  III.,  V.,  IX.,  and  XI. ;  basilar.  Cases  IV., 
VII.,  and  Vlir. ;  anterior  communicating,  Cases  VI.  and  X.;  and 
anterior  cerebral, C'ase  XII.  The  aneurisms  ranged  in  size  from  a  small 
pea  to  a  large  cherry.  With  the  exception  of  Case  IV.,  they  were  sac- 
culated, and  communicated  with  the  lumen  of  the  vessel  by  an  orifice 
smaller  than  the  circumference  of  the  sac.  In  Case  V.  there  were  two 
aneurisms,  one  on  either  Sylvian  artery.  In  Case  III.  the  aneurism 
was  surrounded  by  thickened  meningeal  tissue ;  in  the  others  the  sac 
was  free.  In  seven  cases  the  hemorrhage  was  chiefly  meningeal,  and  the 
laceration  of  brain  substance  was  slight.  In  Case  III.  the  hemorrhage 
was  altogether  into  the  substance,  which,  from  Coats's  account,  seems  not 
uncommon.  The  extravasation  was  usually  basic,  and  beneath  the 
arachnoid  ;  the  amount  of  blood  considerable,  except  in  Case  I.  In 
Case  X.  the  hemorrhage  extended  along  the  right  optic  nerve  and 
appeared  as  a  subconjunctival  ecchymosis. 

In  Cases  III.,  VII.,  VIII.,  and  IX.  tliere  was  heart  disease;  in  Case 
VIII.,  ulcerative  endocarditis.  In  Cases  I.,  V.,  VI.,  VII.,  IX.,  and  XI. 
there  were  atheromatous  changes  in  the  branches  of  the  circle  of  AViliis. 

Embolism,  endarteritis,  and  atheroma  are  the  chief  causes  of  aneu- 
rism, and  the  cases  in  this  series  afford  illustration  of  each.  Although 
it  was  suggested  by  Ogle,"  Ciuirch,''  and  others  that  embolism  played  an 
important  part  in  the  production  of  aneurism,  the  evidence  was  not 
very  conclusive  until  the  i)ublication  of  Ponfick's  observations  in  187.'>.* 
In  several  of  his  cases,  the  connection  of  the  eiid)olus  with  the  aneurism 
was  very  clearly  demonstrated.  Of  the  cases  here  recorded,  four  were 
associated  with  heart  disease,  but  in  only  one.  Case  III.,  was  the  condi- 
tion suggestive  of  the  previous  occurrence  of  embolism.  In  this  patient, 
a  lad  of  '20,  with  aortic  valve  disease,  the  aneurism  projected  directly 
into   an   oval   cyst   witli    reddish-brown    contents,    and    there   can    be 


nil 

Iff 


I 

I 
(  ,     . 
I 
•  • 

! 


1  filiisgow  Mcilic'iil  .Iimrniil,  l«-:i 

3  St.  Uiirtholumew'n  llii.iiiital  llciJurU,  vol   vi. 


=  Mfdicii!  Thiipsiind  Giixcttc,  IHCI 
<  ViiTliuw'3  Aroliiv,  lid.  Iviii. 


21 

ulcc-ativc  ™,l,„:,„,|itis  ,,,,1  a  r  1     ,      .        ^''"■'•"'""-     There  were 

,v:'---  "■^"'  - '^■''^^':::::2:'::"i; ""'  ■",  ■"".  -''■" 

this  part  «as  obli^e„,tc tiliroid  i„  ,1,  .  '■™'  S"'"S  '» 

ancri.,,,,,.     Tl,e  wails  we     ^  '  w, r,"';, .'''"r™  ''  "",'"''"«'  ""<■ 

vel.licJ  on  the  proximal  si,l,.  .,(•  ,1  •         "'°  """'■''■sm  lia.i  de- 

ctly,  of  in.erfele„::      r  ,  e    at:.;  ::':ni  ""  ■"  '°"7"™-'  "l">- 

I"  .l.e  other  eases  associated  ier,'!,:'"t?  '"  '  "j  "^«"- 

•..  >»  -y  .raee  of  previoas  embolic  le  r       'w    „  S  t'  .  7'  T"=!" 
cases  there  were  athoroiivifnM  .  ..I,  •      '"'"^"^'-ted  \  cssels.     In  six 

Willis,  and  I  tIdaU  i:  :^^:::jr  '"  "«'/■«*  of  the  circle  of 
.1.0  fcmmtio,,  of  these  a,  r  .l  p',  ""7  "''"™'  """°"'""  "'"' 
in  II.C  intitaa,  is  verv  com, , T  n  ,1  '    ""■'"""•  "''"'  «'«.v  changes 

I'avc  n,ct  wit  ins  lees  h  hi  h  "  \'°"  ,"""■'"  °'  "'°  '"■""■-•  »«i  I 
arteries  were  chieH;, ,  al  ,  n  ,1  ^l  "n  '"'  ""^  ""'''"'  '"""-' 
tl.ose  eases  under  the  a.-o  of  40         ,  "  ,"»""-<»"-o  of  so  ntan.v  of 

tkcory,  bnt  „„„,.„„„    par  ictd.  rle        '   ":"°    '"  *'""■  °''  ">°  ""bolic 

.vo-g.  A  weak  .pi  in    ;';,:  ;:f ""'  'rS'""-'  ""="'■  ■•■  "- 

S|«iaily  liable  to  yield   as    la,     ■  '" ««  "robral  vessels  w,„dd  be 

co,a,n,,,,ie„ted  fro.n  t^l'e  a^;'!     '  ""  """"  '"'"'"'"'  '"  »  •'"■«ly 

Fn  Case  IV.  tile  dilatation  was  due  fo  I,.,,.,!        i 
|.ossibly  „«,cia.e,l  with  recent, v, I     '     T  ""''"•■";"'"■  "I"-'.   <va, 

lifcatiuna„d  inliltrati,,,,  of    I   ■,;■„,',  ?  ""'■"■•  ""'''"'"""-■lial  pro- 

The  clinical    historv    of  ca    s         '  """■";"• 

mc..,re,  as  the,  .-arcly-eause  ::;  1  ;'  ;;:;;:;-    '»    ■■:--% 

««x,.u  ^,r.io,.,;1;i::;L:'- 
Ability.     Three  davs  belt;  .  i,a^    . ,' ':,  -'"'  "■'!''  '"■"''""'"■  »"" 


^ 


.  I 


mi 


U  1 

! 

i 


fr 


t  .1 


I 


i    ^ 


:.::>! 


22 


p!|[f"-fiiHi 


would  answer  intelligently.  Urine  alhnniinous.  She  remained  in  this 
state  nearly  five  weeks.  On  January  'iolh  the  right  arm  was  flaccid. 
Insensibility  supervened,  and  death  about  si.t  weeks  after  admission. 
The  post-mortem  examination  showed  atheromatous  arteries  at  the  base 
of  the  brain,  and  on  the  left  internal  carotid  artery,  just  before  its  division, 
a  sacculated  aneurism  the  size  of  a  hazel-nut,  which  communicated  with 
the  lumen  of  the  vessel  by  an  orifice  one  by  one  and  one-half  lines  in 
diameter.  The  sac  contained  a  firm  decolorized  clot.  In  the  course  of 
the  middle  cerebral  artery  there  was  recently  effused  blood,  beneath 
which  the  brain  substance  was  lacerated  to  a  slight  extent.  There  was 
an  atheromatous  patch  on  the  anterior  segment  of  the  mitral  valve; 
otherwi.se  the  heart  was  healthy. 

CJasr  ir.  Aiieurixm  of  rigid  middle  ccrelmtl  arlenj. — IMrs.  R.,  let.  40 
years,  married,  five  children,  patient  of  Dr.  John  Bell,  was  i  nd  speech- 
less in  her  bed  on  May  29th.  She  had  been  a  healthy  woman,  but  had 
suffered  with  vertigo,  and  of  late  her  memory  had  failed.  There  was 
left-sided  hemi[)legia,  gradually  deei)ening  insensibility,  and  death  oc- 
curred on  the  night  of  the  30th.  At  the  autopsy,  slight  meningeal 
hemorrhage  was  found  at  the  base  and  over  the  convoluti(ms  of  the  right 
side.  The  right  Sylvian  fissure  contained  a  large  clot,  and  the  convolu- 
tions bounding  it  were  considerably  lacerated.  At  the  main  bifurcation 
of  the  right  middle  cerebral  arteiy  was  an  aneurism  the  size  of  a  bean, 
about  half  an  inch  in  length  and  a  quarter  of  an  inch  in  breadth.  At  its 
under  surface  was  a  rupture  with  a  ragged  orifice.  There  was  no  athero- 
matous change  in  the  vessels  at  the  base.     No  heart  disease. 

Case  III,  Aneurism  of  left  middle  cerehml  artenj. — A.  R.,  ret.  20 
years,  a  small,  but  well-built  man,  died  suddenly  on  the  evening  of 
the  25th  of  March,  and  tlie  body  was  brought  to  the  hospital.  No 
history  could  be  obtained  of  any  previous  illness.  Brain,  on  section, 
presented  a  large  clot  on  the  left  side,  which  involved  the  lenticular 
nucleus,  internal  capsule  and  part  of  the  thalamus,  and  reached  almost 
to  the  convolutions  of  the  insula.  On  carefully  tracing  the  vessels  in  the 
left  Sylvian  fi.ssure,  one  of  the  vessels  was  closely  adherent  in  the  angle 
between  the  insula  and  the  parietal  convolutions.  The  artery  appeared 
to  enter  an  oval  mass  the  size  of  a  large  cherry,  which,  intcrnallv,  was 
in  direct  contact  with  the  clot,  and  on  slitting  up  the  vessel  it  expanded 
into  a  small  aneurism  the  size  of  a  pea,  which  occupied  abjut  one-third 
of  the  oval  mass  above  referred  to.  The  wall  of  the  aneurism  presented 
a  rupture  four  millimotros  in  length.  The  chief  part  nf  the  oval  nin.'w 
was  nride  up  of  a  cyst  with  firm  walls  and  reddish-brown,  pulpy  contents. 
No  communication  existed  between  this  and  the  aneurism,  but  at  one 


5  \ 


28 

point  tlie  connection  of  the  aneurism  •nu)  tl.o 

filM-ons.     A  branch  was  ,ivcn  o     i       "J       ''''  ''''  "^^^  -"«'>  ""^1 

^  as  if  it  ha^I  been  forn.e.r.tt  the   l,  ".  '"""'"'"'  "■'''^•''  '"'>ked 

*  of  NVilii.  were  not  a    e  InJ^      n"^  ?  I'""''     ""^'^^'^^  <'f  the  circle 

of  the  aortic  eusp«;  ^ZtaZj  ''^'l-^^P^-d  ;  fhsion  of  two 

Ca.sk  IV.     Aneurismal  dilafation   nf  L.fi   ..    ,  i     , 

i-i.«i.  Eisi„oe„  ,„„„ti,.,  iK.f„,'  d  t:ito  ;,C;'?  r'',"'  'r;'"  ■" 

sivc  coagiiliini  at  biwo  of  l)ril„  f, ,■         ''"""''"■'  s)'l>l"Ils.     JJxteu- 

tl.o  latter  vosKl  close  to  K  „  ,.  ""=  I'"*''"'' ""'<=li  <lilate,l,  „,„|  in 

as„,al.  per,;,„.    ,  'r.:  e  ,u  f ''■I  ,;"t-™'  "'""'""'  ""'""«" '"> 

P-e.,teU  o,.„,,„„  a.l,e,.::  :■„,.",  ;;:r  ;;- -7".  -'  in  l>i-« 

basila,.,  very  materially  redoced  the  1  ,  ™      t'  "■.»,  «""'°  "*' "«> 

vessels  i,„„„a|.     Heart  l,e,I  hv      No    H  ""'"'"'"  '""'  ^J  '""" 

Male.  tet.  65  years,  patfen  Jt  Art  ,/a  B,  "'n,''"/  "'*"■'"'- 
."onths  ,.itl,  obscure  brai„  sym,Ho,t  Vetb'  .T;  ,  '"'  """"°"=" 
;™.o-,a„d  jost  beyond  the  fl'rst  <livisl  tt  tft'^l^dcr  "''r,' 
^.ere  «as  a  sacculated  „„e„ris,„  ,l,e  si.e  of  a  „c        if  ,  T  '""^'"^ 

On  one  of  the  ,„„i„  branches  of  the  r.H.t  m  ,M| ,  "'  ,"°'  ™''""'^<'- 

was  a  second  small  irreauhr  dil,,.                 ,  '"'"'"■"'  """>'  "'"■= 

an  old  apoplectic  eyst  1     .  ,e  S^^^     '"    ':°,'°"  l>™'«Pl»ie  there  was 
a„e„ris,ns.'  No  valUa;  dt,:: "JhL:!  "''  -"■—-  -'-y 

Pifa  No  history  0  ';rev;,  ill',  :  "cl  '™>"'"  '"  "'»  «»■«"  «»»■ 
fasnre,  and  „  nniforn,  sheetZ  a  he  I,/  f  '"  ,''.'''°"  °''  '""S""'""al 
entirely  beneath   the   „ n<  2d      <^  "  °""'='°''-''  '»'"«  ">  "<»■''. 

basilar  and  ndddle  reb^l  the^'c:!;?,-'""'^  "'  ""'"'"""  ^ 
Willis  revealed  a  .mail  .,„e,, .  li  "'  ''"^""^tion  of  the  circle  of 

»n,m„nica.i„g  arte  an  T  '",""  ^T"'"'^  ^""''  ""^  ""'«"<>■• 
tniMin,e.res  in  lengl''  T      Z      :'lf  ,T       M  '1  '"'"'"=  '■""'"-  ''^ 

-;.«!  a  spot  ..f°atherom::::  -r:-  c:™'St:r'"'''v''"V''^^ 

atheromatous.     Kidncv^  ■,  IJtH.  """ce.     lleait   normal.     Aorta 

r        \rrr        .    ^'"^^^ '^  ""le  granular. 

V-Msio  VII.     Aneiiri.vn  of  basilar  nrtp,;j~  J  « 
Death  from  thrombotic  « 'ft..,:..    :.     '.! '^    '^•.  ^V  «^'^'-  7'>  .vears  of  age. 


at  the  base  atheromatous.     A 
nected  with  the  basilar  arte 


iiig  in  left  hemisphere  of  b 
11  aneurism  the  size  of  a  lai 


ram. 


T  r 


:1s 


iry,  a 


■gc  pea  was  con- 


^^   I:  h 


'■  1 

V: 

i' 

'k  1 

!■   . "( 

V.      1 


'f 


Ij 


ll^ 


]       ,  ,  -«"    J-.-11    iliio    ui 

nd  lay  imbedded  in  a  shallow  fossa 


in 


H  - 


I  -"il 


24 

tlie  pons.     The  wjills  wore  tliiolc,  and  did  not  contain  tiirondii.     Heart 
liypertnipliied.     Aortic  valves  ineoinpetcnt.     Perieardiiun  adlierent. 

Casio  VIII.  Aiifiin'mn  of  Ixisilur  ((rtn\i/.—'M.  W.,  male,  a't.  4.')  vears. 
Had  had  syphilis.  Admitted  with  pneumonia,  and  developed  ulcerative  * 
endocarditis.  An  aneurism  six  by  five  millimetres  projected  from  the 
upper  wall  of  the  basilar  artery,  about  its  centre,  and  had  formed  a  hod 
for  itself  in  the  pons.  It  did  not  contain  clots,  branches  of  circle  of 
Willis  not  atheromatou.*.  Heart  a  little  hyperlrophied.  Recent  ulcer- 
ations on  aortic  and  mitral  valves. 

Cask  IX.  Anenrium  of  left  middle  vcrehnd  artet-ij. — Female,  ict.  40 
years.  Died  of  pneumonia.  Vessels  of  circle  of  Willis  slightly  ather,)- 
matous.  A  i)atch  in  the  basilar  narrowed  its  lumen  considerabiy.  Just 
beibre  the  first  bifurcation  of  the  left  Sylvian  artery  there  was  a  saccu- 
lated aneurism  the  size  of  a  pea.  The  wall  of  vessel  about  it  not  athero- 
matous; no  clots  in  interior.  Heart  hypertrophied ;  vegetations  on 
aortic  valves. 

Casio  X.  Auciiri.'Oii  <if  <uiterlor  eominunicating  tirteri/. — G.  E.,  a  lad, 
set.  17  years, admitted  December  18th  in  an  insensible  condition.  Three 
months  previously  had  an  epileptic  tit,  from  which  iie  (piickly  recovered. 
For  eight  days  past  had  had  severe  headache.  He  remained  uncon- 
scious and  died  on  the  23d.  Ecchymosis  of  right  upper  eyelid  and  con- 
junctiva developed  while  under  observation.  Extensive  hemorrhaoe  at 
ba.se  of  brain,  involving  meninges  and  extending  along  the  anterior 
cerebral  arteries  upon  the  corpus  callosum.  On  separating  the  orbital 
plates  of  the  frontal  lobes,  and  carefully  removing  the  clots,  an  aneurism 
(measuring  10  bv  11  millimetres)  was  seen  occupying  the  longitudinal 
fissure.  It  was  partially  imbedded  in  the  adjacent  brain  tissue,  which 
was  a  little  lacerated.  On  dissection,  it  was  found  to  spring  from  the 
anterior  communicating  artery  by  a  very  small  orifice  situated  close  to 
the  right  anterior  cerebral.  The  sac  was  full  of  dark  blood,  walls  verv 
thin,  and  presented  a  rent  of  2  millimetres  in  extent  at  the  lower  part. 
Other  vessels  of  the  brain  healthy.     No  heart  disease. 

Case  XL  Anenritim  of  left  middle  eerebral  artertj.—W onwm,  ;ct.  (12 
years.  Admitted  in  a  semiconscious  state,  with  right  hemiplegia,  win'ch 
came  on  after  a  fit  three  days  before.  Death  occurred  on  the  seventh 
day  after  admission.  There  was  extensive  hemorrhage  in  the  meninin'S 
of  the  left  Sylvian  fissure,  and  thin  clots  also  at  the  base.  The  inner 
and  anterior  part  of  the  left  temporal  lo'iu  was  lacerated.  A  small 
sacculated  aneurism  the  size  of  a  pea  was  found  on  the  left  Sylvian 
artery,  just  within  the  fissure.     The  walls  were  extremely  thin,  and  the 


■f  '  '"■  A 


25 

::":r  ;;:::;;;;x  J"° ''''-"  "'"■  -'-'-"  ^^-""^  >- ^™- 

^;..  »o„  o„  .1,0  H„.  »*,„,;j':„f;;;-,.i;;T  „  *  ;:Er 

0  ti,o  c„„t,,.,„„„  |„„,i„„  „,.„,„  ,„,_.,,  ^^^,_^^^^       „„: ,  : 

Mlior„„mto„s,  and  the  heart  „a»  healthy 

eerel,r,'rhr'""'i"  "•■•''""'"*'"  »''  "'<=  <«'V  «rt^'™»  i-s  »  lre,,no„t  c«,.e  of 
coub.al  he„,or,-hase  ..,  person,  „„,h,-  Cofty  ve„,,  ot„,.e;    n  the  e„li 
cnee  of  .,on,e  |,„,h„h,,tas,  the  „,«it  common  cause.  '"«- "Lm- 

J%  i;5,  ],s8(). 


V  '■ 


Ancurls>n  of  thoracic  aorta ;  perforation  into  left  pleura. 
Miibel  W.,  ;ct.  22  yours,  was  a.lnutted  to  the  Phil-ulelnhi.,    U  .  >  i 

,|m,  ,„  the  c,„g„st..i, .„,,  left  sijc.     I  ,„„<,e  „  e„,.cf„    Z    '      „    of 

and  in  a  few  minutes  fell  dead  on  the  bed  ' 

Autop.j.-On  opening  the  thorax,  the  mediastinum  with  the  heart 


V:  M' 


t|-9 


f      , 


ii  r 
) 
i 
I 

c 
1 


if     i 


:  I  if  II 


26 


WHS  pushed  to  the  right  by  an  extansivo  hemorrhagic  effii.sion  into  the  left 
ploiini,  iimoiinting  to  several  pounds.  The  lung  wiis  colliipsed.  When 
the  pericardium  was  opened,  it  was  noted  that  the  apex  of  the  heart  was 
not  pushed  beyond  the  middle  line,  and  the  oblique  position  of  the  organ 
was  retained  in  si)ite  of  the  dislocation  of  the  mediastinum  by  the  large 
effusion. 

Ilcnvt:  Right  auricle  contained  about  =j  of  blood  and  clot.  Left 
auricle  and  ventricle  empty.  On  further  dissection  valves  normal,  the 
arch  of  aorta  smooth,  muscle  substance  pale  and  flabby. 
^^Aurta:  The  arch  was  small,  and  the  lining  membrane  healthy. 
Thoracic  aorta  looked  normal  until  level  of  the  nintli  vertel)ra ;  here 
there  was  an  opening  on  the  posterior  wall  an  inch  and  a  qmirter  in 
lengtii  by  a  half  inch  wide.  The  contiguous  parts  of  the  aorta  looked 
infiltrated  and  swollen.  This  orifice  communicated  with  a  sac  full  of 
clots,  whicli  lay  immediately  in  front  of  the  tenth  and  eleventh  vertebne, 
and  projected  into  the  left  pleura,  where  it  was  closely  united  to  the 
diaphragm.  At  the  point  of  greatest  prominence,  there  was  a  transverse 
laceration  a  half  inch  in  length.  Tlie  sac  was  about  the  size  of  an 
orange.  The  bodies  of  the  nintli  and  tenth  vertebne  were  eroded,  the 
latter  most  deeply.     The  cartilages  were  not  involved.     No  changes  of 

November  11,  188G. 


note  in  the  other  organs 


^  t 


■M 


\St  :■ 


Small  (Dieiirisms  of  arch  of  aorta ;  compression  and  perforation  of 
trachea;  death  from  suffocation. 

Dr.  Osier  exhibited  the  specimen,  and  gave  the  following  account 
of  the  case.     Patient,  an  Englishman,  let.  32  years,  had  come  to  Phila- 
delphia on  his  way  to  Colorado,  as  he  had  been  advised  to  winter  there 
by  his  English  physicians,  wlio  suspected  the  existence  of  lung  disease. 
He  had  been  in  Australia,  where  he  had  lived  a  very  active  life.     Had 
had  a  chancroid,  and  had  taken  alcohol  in  excess.     For  nine  months 
before  leaving  England  he  had  a  cough,  much  worse  at  times.    He  came 
to  the  hospital  August  31st,  complaining  of  weakness  and  severe  cough. 
Examination  of  the  chest  revealed  no  special  areas  of  dulness,  but  many 
rales,  mucous  and  sibilant,  in  front  and  toward  the  bases.     At  times  the 
cough  was  very  rough  and  hard,  and  there  was  much  wheezing.     Tiiere 
was  irregular  fever;  the  temperature  on  14th  reaching  102\    Remedies 
had  very  little  influence  on  the  cough.     On  the  17th  he  was  foun-'  in  a 
condition  of  stupor,  and   it  was  thought  that  he  possibly  had  taken 
morphia,  but  the  next  <lay  he  was  brighter.    On  the  21st  there  was  blood 
with  the  expectoration.     On  the  24th  he  seemed  as  usual  through  the 


i'i#. 


27 

emlmrrassed,  and  he  l,..,!  .r.-o./  rl-     u  '"^'^tlun^r    |,,,,iiut.    much 

<iead.     The  face  was  suffu  ed  and  V  tie    "  F          l-''       "'"'  '"'"'^ 

nftorwunl.it  see.ns  that  he  had      e^^  Ub  J     f      ''f   """"'"' 

he^had  take,,  hi,-gely.  "^  '''"'''''^'''  "^"  ^^''i^'' 
-The  an topsv  showed   tho  Ihm,-.   f     i 

l''-<'  exuded      '^/;l^^  r'"'^-'  ope„i„g,  th,-ough  which 

of  aorta  n^d      d    u  d'the  TT     "T  '"  "'^'"  '^'■''*^^'^-     ^'^^  -^^ 
j.K^t  at  perica rd  Hi'  a  tLh        .      '  ''^''^^""^'^^"•--     «"  a„te,.io,-  surface.  , 

te.-io,-  wall  of  th      n  „let  "'"';"""^*^  ""^  ^^^  dilated.     On  the  pos-   ; 

filled  with  fi  r  0    , Tr  f"'  "■"'"' '''  ''■''''  '^^'-  --'  -- 

two  shallow  pouedn^e  i    I  "'     "  ';"""  "^^^  ^'^^  ^"^^'^-^  -- 

organs  presen!:'n:X^:r"'  ""   '"'   ^^•^''    ^^"^^^     '''^  "^^^- 

those  of  severe   ^::^rXu^^:  '^      ^""^^""^  ''"''  ^^'^'^"^^^ 
had  caused  the    nten«o  /,,'""'"?•      ^'^^  eo,upress,on  of  the  t,-aehea 

the  bronchi ;:;:'  :^S  xfr wiS"'"'"'':;^'^:  '^^  *^  ^^^"^^'-^  ^^ 

suffocative  process  '^  '™"''^'  ^^  """''•^'^^  '"'^ten  the 

0(!<o6e/-8,  1880. 

^-.m«  0/  W.  <jr  „»W„  -  „,„„„  ,■„..  «.  „.„.,„,  ,,  ,„  ,„,„^ 


I!     ( 


It,'     I 


I     I 


u 


if 


*J^ 


!■'      'S- 


\ai 


■I 


US 

August,  1«.S2,  he  hogan  to  siifriT  with  imins  in  tho  cliost  iiiul  left  shoiildor, 
l)iitlK-(li(I  11, .t  Iiiivc  iiiiy  Kcrioii.s  im;  .iiveiiiencc  until  Scpteinhcr,  1«8;?.' 
when  Ii(>  wius  attacko.l  with  coiigli  and  thomcic  tronhh',  po.ssiblv  pul- 
monary, whicli  kept  him  in  tho  house  and  in  hed  for  several  inonths. 
It  was  not  until  May  of  last  year  that  he  was  able  to  work.  Since  July 
be  has  had  at  limes  attacks  of  shortness  of  breath,  with  whce/.in-r,  and 
often  at  nij-ht  he  has  to  sit  np  in  bed.  Within  the  past  three  weeks 
the  pains  in  tiie  shoulder  and  down  the  left  arm  have  become  very  severe 
and  the  couali  and  shortness  of  i)reath  have  increased. 

Note  on  admission  was  as  follows:    Well-built  man,  face  thi-i.  f,'eneral 
musculature  ^^ocxl.     In.spiration  rough  and  noisy,  expiration  long  .,iid 
harsh  and  often  accompanied  by  a  bra/en,  laryngeal  cough.      Respira- 
tions 1«  per  minute.     Can  rest  in  tlic  recumbent  jmsition.     On  inspec- 
tion, the  left  side  of  the  neck  is  much  flattened,  especially  above  the 
clavicle,  and  the  sterno-mastoid  muscle  on  this  side  is  evidently  atro- 
phied.    Ajiex  beat  visible  in  normal  positicm.  no  abnormal  imlsatitm ; 
slight  visible  pulsation  in  vessels  of  neck.     Paiputlon  in  the  ordinary 
way  negative,  but  on  firm  pressure  with  one  palm  on  the  upper  bone  of 
sternum,  and  the  other  on  the  back,  a  decided  impulse  can   be  felt,  and 
the  second  sound  is  accentuated;  deep  pressure  reveals  pulsation  above 
sternum  and  behind  the  left  sterno-clavicular  joint.     Percussion  reveals 
a  slight  area  of  dulncss  in  the  left  half  of  the  manubrium  sterni  and 
beneath  the  leit  sterno-clavicular  joint.     Heart's  <luliu\«s  not  increased. 
Auscultation  :  heart  sounds  clear.     At  sterno-clavicular  joint,  wlieii  the 
breath  is  held,  there  is  a  soft  double  imirmur,  the  diastolic  the  loudest, 
and  the  second  sound  is  markedly  accentuated.     These  murmurs  can  Ik' 
heard  over  the  left  carotid  and  on  supra-st'!rnal  notch.      Tugging  at 
trachea  is  marked  on  elevating  the  larynx;  pujjils  equal. 

Tho  left  radial  pulse  is  smaller  than  the  right  and  is  slightly  retarded. 
Lungs  negative;  loud  tracheal  and  bronchial  stridor;  no  pressure  signs 
on  either  bronchus.  Patient  expectorates  much  thin  muco-serous  fluid 
which  is  blood-tinged,  and  at  times  there  are  more  consistent  sputa  con- 
taining much  blood.  He  was  ordered  to  take  twenty  grains  of  potassium 
iodide  three  times  a  day  and  rest  (juietly  in  bed.  No  restriction  as  to 
diet.  On  examination,  laryngoscopically,  the  left  cord  was  Ibund  iiii- 
moi)ile. 

Within  three  weeks  he  was  greatly  benefited  ac  regards  the  pains,  the 
cough,  and  wheezing,  and  (he  blood"  had  disappeared  from  the  sputuni. 
Throughout  February  he  remained  very  well,  having  occasional  attacks 
of  spasmodic  coughing  at  night  which  were  relieved  by  spt.  lether.  co. 
His  general  health  improved  and  he  was  allowed  to  go  about  the  ward. 


29 

SputUH.  ..cccasionally  .stmilu.l  with    l.lo.xl.     O,,  M,,,.],    10.1.  I, 

:-.  Is  lino.,  „,„,  .,„„»  .«iio"«ri;:::i\:';^::\rHr ":,':;': 

innonunute  and  left  nm.ti.l  are  free-  that  of  ,1  n     n      .    ,  "" 

.."..■1.  -..c,.ea  liltr;;;:;!  ':ci  ■;  .!'n:zr'  i"  t"  r ' 

■»'l)-  tw„  ,„■  ,!„„„  ,„illi,„efos  i„  .li„       J      „        L        l"l"™«."".  .. 

>  ana  m  a^tate  ot  fatty  degeneration  and  broxvn  atroDliv 

e  ponus  of  ,ntcre.t  in  this  case  were  the  repeated  blee  i  ..  extend 


t 


.  !?'■ 


r 
> 

! 
! 

I,' 
C 
\ 

hi   i 


■I:i 


IP 


ijl^ 


;.  !'  ^i 


1    .■^, 
If  '■' 


ii     i-i 


^•i 


I: 


1 


80 

indication  that  erosion  of  tlie  trachea  had  occurred,  but  Nuhsc(|U(<ntly  it 
was  thougiit  more  prohahlo  tiuit  it  came  from  tlie  hwoIIoii  nnicosa  ut  the 
site  of  comprosHiou.  No  doultt  tlie  first  Hiippo.sitioii  wns  the  correct  one, 
as  the  upper  of  tiie  pcrforatiouH  iiml  prol)iihly  l)i'cii  tlie  .source  of  the 
blecdinj,',  l)ut  the  firm  leatliery  clots  effectually  prevented  any  profune 
hemorrha^'c.  The  fiiuil  hleedinj;  into  tlic  o'sopluijjus  also  took  place 
very  slowly,  prohahly  (liiriiitr  the  last  thirty-one  hours  of  life,  as  there 
was  dark,  much  altered  hlood  in  the  ilium. 

It  is  impossible  to  say  upon  what  the  atrophy  of  the  neck  mu.scles 
d(>peiidcd,  as  no  careful  dissection  was  made  of  the  nerves  in  that  region. 
Possibly  the  sympathetic  was  affected,  but  there  were  no  diflerences  in 
t''^  l>iipik  Ajyrtr.),  LSS,"). 

»'       ' 


Jinpfara  of  the  posterior  papillary  muscle  of  the  Ivjl  vcutride 

of  the  heart. 

li.  l\,  ;et.  about  70  years,  a  hir<,'e-framed  negro,  was  in  Ward  (>  of  the 
Philadelphia  Hospital,  tour  months,  with  .symptoms  of  mitral  valve 
disease  and  heart  fiiilure.  When  I  first  saw  him,  about  a  month  before 
his  death,  the  legs  were  swollen,  and  the  urine  scanty.  There  was 
orthopncea,  and  slight  effusion  existed  at  right  base.  The  apex  beat  was 
outside  the  nipple  Hue;  impulse  forcible;  and  a  systolic  thrill  ccjuld  be 
felt  in  the  apex  region.  There  was  a  loud,  rough  systolic  murmur  heard 
well  into  the  axilla.  The  pulse  was  irregular;  superficial  arteries  verv 
atheromatous.  Ilis  history  was  not  very  clear.  He  had  been  a  hard 
worker  up  to  a  few  months  before  his  admission  to  the  hospital.  His 
symptoms  appear  to  have  come  on  gradually,  and  throughout  were  tho.se 
of  mitral  insufficiency.  Three  weeks  prior  to  his  death  Cheyne-Stokcs 
breathing  came  on,  and  persisted  without  intermi.^sion.  During  this 
time  he  was  well  enough  to  get  out  of  bed  for  his  dinner,  and  at  this  time 
he  was  repeatedly  seen  to  wait  for  the  urgency  of  the  respiratory  move- 
ments to  pass  away  before  taking  a  mouthful. 

Body  that  of  an  elderly,  well-built  man.  (Edema  of  legs,  back  of 
thigh.  Abdomen  contained  a  small  amount  of  serous  fluid.  In  thorax 
effiision  into  both  pleural  sacs.  Pericardium  contained  a  moderate 
amount  of  fluid.  The  pulmonary  veins,  arteries,  and  also  the  aorta,  were 
filled  with  dark,  firm  clots.  Right  auricular  appendix  filled  with  an 
ante-mortem  clot  softened  in  the  centre;  several  globular  concretions  in 
the  neighborhood.     The   right   auricle  was   much   dilated. 


ricus] 


lid 


nng. 


\v\  4.' 


■f ''^^  i-i ..„.,  r:1 1    '    J?,;;::  ;;;;i;'-''.  ■■-•■"'«■ > » lari. 

.t.'m,..,.,l.     I,,i   v,.„u  Ml,'       ^,"'"'^"^■* ■'■'""  "' I-  ""I 

■■■•■""  "f  rnurni  ,i,i„  „„ , ,     ;„„;;"■":;■  7-'^"'"i-.  A-'-i--  »«■ 

III.,  i,„»ti.noi-  »,.t„,„,M  „-,„  „„„„,|  „(  ,.  „  „    '"  '"  ""«  "'  'I'l"  "CgiiK.iu. 

nvooi„„,,„p„.,„,  „'  ;  ,„.';,|::  ;•';"■:  ""pi"...,-  ,„„,dc  «„„.,„. 

«»II  ..f  11,0  vent,"  I,  ;,„  '"■"  ""  >•<'»«'»"■■"»■      <)"  ll,c  |,..,lc.,i„r 

Wall,  „n,,c  left  „:,  ,e  ttr^ , :,  :;■;:.■" ''™"-"''  ^'°°''  »'-■ 
.o:;:;:;:t:t:::;;;':;;;::i;r:?t:::;r™r™'''-"'T-"'" 

uiKloiililcdIv  tlie  til,  „f  , ill        '"'"'V       ^"1™  "'TO  nctached,  to  be 

» I-- "  n-w-  fii„-c  c«:i  t; ,  1 1 ;; "  ''""''»""•  "'- 

"""v  experience,  an.l  I  do  not  re.Ln  .    ^l  '      '"'"  "  ""''^"^ 

literature.    Ti.e  absence  o    v  1  r  .        '''''  ""■'^'  '"^  '»^^""^'«  "> 

absence  of  ^egetatIons  on  the  torn  surfaces  is  interesting. 

iVrt/-t'/(  10,  1887. 
Trvo  cases  of  four  leaflets  to  the  pulmonary  valve. 

«'"'|,ii'il  liva  fourth  .„„„„„„      ,  ■''"  "''j-'<^™'  '■»!«  » 


I  I 


i<  f 


I' 


i(:  I 


I  S :;  i 


I 


32 

Case.  I. — Between  two  cusps  there  is  a  space  3-7  nun.  in  wicltli,  wliich 
is  occupied  by  a  small  semilunar  valve.  It  has  a  well-marked  curvi- 
linear l)ase  of  attachment,  the  free  nniri,nn  is  H  mm.  in  length,  presents 
no  corpus  Arantii,and  is  anchored  to  the  artery  wall  by  a  small  narrow 
tag.  The  depth  of  the  valve  is  N  mm.  The  lateral  attachments  are  to 
the  adjacent  cusps,  not  directly  to  the  artery.  Two  or  three  fenestra- 
tions of  the  large  cusps  communicate  directly  with  the  pouch  of  the 
small  one.     The  three  segments  are  of  eipial  size,  and  normal. 

Cask  II. — Between  two  normal  looking  segments  there  is  placed  a 
small  cusp  7  mm.  in  width,  8  mm.  in  depth,  with  a  distinct  crcscentic 
margin  of  attachment  and  a  curved  free  border.  The  lateral  edges  are 
united  to  the  contiguous  valve.  The  sinus  is  distinct  and  does  not  com- 
municate with  the  adjacent  ones.  The  adjacent  cusps  look  a  little 
smaller  than  the  third.  November  11,  1886. 


Bicuspid  jmhnonary  valve. 

In  a  case  of  carcinoma  ventriculi,  with  enormous  secondary  mediastinal 
growth,  the  i)ulmonary  valve  presented  the  following  peculiarities.  The 
orifice  was  guarded,  by  two  segments.  The  smaller  measured  So  mm. 
along  the  free  border,  was  M  mm.  across  the  face,  presented  two  fenes- 
trations, and  there  was  no  distinct  corj)us  Arantii.  The  other  segment 
measured  o()  mm.  and  across  the  face  1")  mm.  The  free  border  was 
thickened,  presented  no  distinct  corpus  Arantii.  The  body  of  the  leaflet 
was  also  a  little  thickened.  At  the  attached  margin  there  was  a  sli'dit 
indication  of  separation  into  two  segments.  On  the  arterial  face  there  was 
a  small  median  raphe  which  jjassed  from  the  arterial  wall  to  the  base  of 
the  segment.  Here  it  expanded  into  a  seri'-  of  radiating  fibres  which 
extended  along  the  inner  surface.  This  in  .^au  raphe  separated  Iwo 
sinuses  of  about  equal  size.  Decey/iier  9,  1880. 


Large  phlebolith  of  l())if/ tiajjhoioas  vein. 

The  specimen  was  obtained  from  G.  H.,  an  elderly  man,  who  died  in 
the  Philadelphia  Hosi)ital  of  fatty  and  dilated  heart.  The  tumor  was 
noticed  during  life,  but  there  is  no  note  as  to  how  long  it  had  existed. 
There  was  no  sign  of  a  wound  or  of  external  injury,  though  the  .size  and 
situation  suggest  that  it  may  have  resulted  from  traumatism. 


*• 


83 

ati:^:!;";;^^;:-^:::::^^-'^;  f^'-'^-^^ '--'-  ^'-^-^ 

relations  o,.  ,lis.ection    werel  X„o,^     ^r?  ''  T  '''"'"•      ^^^ 

di.-cctlybe„oathit.ndwas„ottvS    F^       f  '"'''"''  '^'"'^ 

of  tlie  long  saphenous  vein  oecl  1  'l,  T  '"'"  ''"''  ^'''■'-  ^'•"'^« 
on«-.  The  occlusion  u^a  tl  t  /  T  '  ''""'""  "'  "^  '"'^''  ^-■- 
Pi^^'l  the  upper  end  of  th    Ion  .   .  ,  T  ■"  '"^^'^^'""^^^l-  ^^^hich  occu- 

^7  heio!.;  ana  ente.:;^!:!:^^^:' at  J';;;  r  ^%  '--'-- 

and  a  ,,uarter  fron.  the  ie.noral  vein  If  .  '\*^f '"''^^  "^  ''»  ■'"ch 
funor  by  three  or  four  sn.all  n    s.  -  O         "•        ?  '"""'"'^^'^  '"  ^''^ 

nally  a  dense  fihro-calcare  s '  i  T"  !  ''""""'  ''  ^^'■'^■^^'"^^^''  --^or- 
ably  consistent,  altered  bZl  '  ''"  ^""^'^"^^  l^'-ownish,  toler- 

Febmanj  10,  1887. 


^"  '^'^  '"'''•^'■'^  ""«'«'»y  o/-;;„«,,„„,.,-„. 


My  post-niorte.n  records  include  105  cases  of  Inh 
^vluch,  with  one  or  two  exconHn..  ,      ""  pneumonia,  all  of 

Hospital.  For  the  V^:,Z!^^ ^^rt  Tt  'iT'^'  ^^"^^'^^ 
-''K'l>  the  data  are  incomplete  s  i  o  '  '"'''"''  "^'^  ^^»^^«'  '" 
tl>e  death-rate  fron,  this  dsete  is  hi  1'!  '  '""f  ^"'^^  ''"^'''^'''^' 
••"'^^""ly  the  severer  casesTre  b  "^^^^  fact  that,  as  a 

siderable  proportion  of    le  cat  '       '"  '  ^^"'^' «^««"''.  that  a  con- 

Paupors,  who\.apidIy  l:!;:,!  :::j;':;;-;;;f^;!'^^'  "»<•  ^Hssipated 
In  the  statistical  re,)ort  of  Dr  T...  n  '?  '»"^^ction  as  pneumonia, 
ten  years  was  aon.ewl  0.^2.^1^'  ''^rT'"''  ''''  "'  "^'""^  «^' 
ring  within  fortv-ei.d.t  hou  s  . ,  "  ""'    "'^  "^^''^  ''^'^^''^  "^''^•r- 

«ta.ed  that  the  nun-tali  v  ,'  c  l'"'?"-  ^^  '  '''''''''''  ''  '^^-^  »^« 
P'-of  R.  P.  Howard,  of^A  „t  ^  Z-i'.;  '""""T'^  "  ^'"  J"'''^'^'™  "^ 
onl.v  4.8  per  cent.  '  '"""=  "^  P''^""^  «^  twenty  years,  was 

The  statistical  details  are  as  follows  • 

^-.--Of  the  100  cases,  70  were  iu  n.ales,  and  :)0  in  fon.ales 

■K^tl..  18;  between  40t    and  -0      T\    I       V''  ''''''''''  ^^^'^  -'d 
over  60,  20  cases,  '  '^  '  ^''''''''  ^«^''  '">J  60th,  12 ;  and 

lung  alfhrted.-Jn  M   case.,  th 


As  to  the  j)osition  of  tlie  infl 


'e  right;  in  32  c; 


ises,  the  left;  in  17 


Montreal  Genenil  Hospital  Iloports, 


amed  region  in  the  lung  the  % 


ures 


vol.  i.     Daw- 


son Uros.,  1880. 


f  •  ( 


.    ■  t 


r 

)■    i 

I 

I 


c     ■ 


( 


1 .1  •■ 


» 


.!i 


i 


m 

II 

^  ■  ii 

:{!■ 

-^H 

I 

^f          : 

M 

! 

1 

/ 


34 


•;  :l 


h. 


;    ! 


4  .1  a 


are  :  in  the  right,  whole  organ  solidified  (except,  perhaps,  narrow  margin 
at  apex  and  anterior  border)  in  17;  lower  lobe  alone,  in  18;  upper 
alone,  in  7  ;  middle  and  lower,  in  3;  middle  and  upper,  in  2  ;  up])er  and 
lower,  in  8.  In  the  left  lung,  entire  organ  in  10 ;  lower  lobe,  in  10 ; 
upper  lobe,  in  6.  In  the  cases  of  double  pneumonia,  it  was  most  often 
the  lower  lobes  whicli  were  affected  together,  but  in  three  instances  the 
lower  lobe  of  one  lung  and  the  upper  of  the  other  were  affected;  in 
three  cases  both  u])per  lobes;  and  iii  Case  LXIX.  the  most  extensive 
inflammation  of  both  lungs  occurred — the  left  was  in  a  state  of  uniform 
red  hepatization,  with  the  exception  of  the  anterior  border,  and  the  right 
iu  the  stage  of  gray  hepatization,  excei)t  still  smaller  portions  of  the 
corresponding  regions.  Altogether,  in  159  instances  a  lower  lobe  was 
involved,  in  19  an  entire  lung,  and  in  16  the  upper  lobe. 

Weight  of  lungs. — To  estimate  the  amount  of  solid  exudation,  the  lungs 
were  generally  weighed.  The  heaviest  was  in  Case  XLVIIL,  a  i.ian 
ret.  40  years,  whose  left  lung,  uniformly  solid,  Aveighed  230)>  grammes, 
and  the  right,  very  congested  and  (edematous,  900  grammes.  (The 
normal  lung  weight  is  between  (iOO  and  700  grammes.)  In  eight  ca-^os 
the  affected  lung  weighed  about  2000  grammes,  representing  rather 
more  than  three  pounds  of  solid  exudate. 

State  of  lung  tissue  affected. — In  about  one-half  the  cases,  the  inflamed 
area  was  in  a  state  of  red  hepatization.  In  oO  per  cent,  there  were  regions 
of  gray  hepatization  with  the  red,  and  in  22  cases  there  was  gray  hepati- 
zation, cither  dry  or  passing  into  the  condition  of  purulent  infiltration. 

State  of  uninvolved  portions. — Usually  the  crepitant  parts  of  the 
affected  lung  were  greatly  congested  or  intensely  cederaatous.  The 
latter  was  invariably  the  case  when  the  whole  organ  was  involved, 
except  the  apex  and  anterior  border,  which  then  presented  a  condition 
of  almost  gelatinous  ivdema.  Tlie  unaffected  lung  was  generally  con- 
gested and  (edematous,  particularly  at  the  posterior  part.  It  was  not 
uncommon  to  find  the  anterior  portions  quite  dry  and  bloodless,  while 
the  dependent  regions  were  full  of  blood  and  serum.  No  doubt  tliis  is 
largely  due  to  post-mortem  subsidence.  We  do  not  always  find  exten- 
sive congestion  or  oedema  in  the  uninllamed  parts.  Thus,  in  Case 
XXXIL,  in  which  the  lower  lobe  of  the  right  lung  was  hepatized,  the 
upper  and  middle  lobes  were  noted  as  "  very  dry  and  bloodless," 
whereas  the  left  lung  was  a'denuitous,  except  at  its  anterior  borders. 
So,  also,  in  Case  LVIIL,  a  woman,  tet.  .W  years,  with"  red  hepatizaiion 
of  the  left  lower  lobe,  the  upper  lobe  was  crepitant  throughout,  dry  on 
section,  no  redness,  and  no  blood.  The  right  lung  was  also  crepitant 
(except  a  fibroid  apex),  dry,  no  (edema,  and  very  little  blood. 


i 


II  I 


"^m 


35 

The  „.ncoas  n.en.brane  v  uZw^u  /""""""^  -'P-torution. 
a«oete<l  regions  the  snutllcr  bron  i  ;""''  ''''''^''  ^^^""^"-     I"  the 

and  in  twelve  instances  tl  e  ^  '  o7  "  ","'""''  ^^""-•^  P'"g«. 
into  the  Jarger  tubes  of  t  infl  d  "  "7  ''^""'"^^  '"^"^^  ^'^'^^-'^'k 
bronchi.  '""'""'•'  '  ^S'«"'  ^*'i-'"ing  perfect  casts  of  the 

neplenra.~\y\J  L  ;   .  '  ''"'  ^^''''  «»PP"ration. 

the  pleura  is  ineW;:bly  L:^  7!^  r^'"/'^  ^"^^^^  «^  *'^^  ^-^ 
sheeting  of  exudate,  pa-hl  of  s  r  '''"^''  '"'""'"''^'  ^^^"  '"^  thin 

turbidity  of  the  n.embUe'  la  ,:;''■"?'  '''''  '''  P™^--  only 
deep-seated,  and  did  not  relh  ^  1  ".  """  ''"  ^""'"^""''^  -- 
membrane  was  involved  in  a  irre.te  •  ^  1  '  '!'  '''"''^'  ''*^''  ^""'^'"^"^^  this 
fibrinous  exudate  was  extraorcHna  1  i  H  '7?  '"  ""'^  ^'^^^  *^- 
in  which  the  right  lun.  w-^s  nn  f  ^i  ^'"''rf"^^  extensive,  as  in  Case  V., 
ounces,andeve^port^;:n:Z^::^:;^;^;f^^ 
hxyer  an  inch  in  thickness  '     !„  Z'lrf  ,      ^  ^  ''''*'^'">'  «^^'''"o»« 

exudation  amounting  to  tliree  or  four  'in  t''  'f '''•''"'  '"^'"'^  ■^^''""^ 
extensive  double  pleurisv  w.Vh  n„  •       *"       "  ^'"^  ^'"^^^^  there  was 

il'-trated  how  reLlil    S^  nt      X" "  7, '''''  ""^  ^'^'^^^     ^'^^  ^  V. 

-;:a-p-.omthepCr;;-^^ 

-  wonder  that^hJif ;^;Y;:'i:!jT""'"V"f '"^""  ^^  ^^'-"-^^ 
-ore  freciuent  result  o7  this  p  ^  ;?  ^77  ^'l^  ^""-^  ^-- -  "ot  a 
definite  small  abscesses.     In  cL  Yvv  v"   "''^"""^^  ^here  were 

^vith  gray  hepatization  of  the  right  uppetlobe  T.  '™"'""'  '''•  '^  ^'''''' 
cavity,  the  size  of  a  walnut  wiM.     .        /         '    '"''''  ''''*'  ''^  ■-'"^11  abscess 

of  the  lobe.  The  tiC  Ij  .th  a's^f  ^'  ^"  '''  ''''^''^  ^-^•- 
n  Case  XXXVL,  male,  .t.  69  v";  I  "'/"''"^^"^  '"^'^^-tion. 
half  of  left  lung,  there  were  in  the  m  ;,  ?'^.  ^^P'-^^'^''^'""  «f  upper 
«pots  of  softening,  the  size  o  i  ^1^1  '".l'''''^'- ^'''^^  ^^^'^^^ 
-:•  13  and  purulent  contents.  In  (^.se  Lxxvrr'  T  '  r^^'"''  ""'^^^'^ 
'■  -bnost  uniform  nnn...i:.,.-.:.,       f  f  f^'^^VlI.,  female,  let.  64  vears. 


.«tate  of  intense  purulent 


'd.'Uion  of  loft  lung,  the 


infiltration,  and  the 


"Pper  lobe  w 
re  were  in  the  middle 


Slieciiiieii  in  tl. 


as  in  a 
por- 


''  iiinsoum  of  MoOill  Coll, 


i-'gf. 


■i^i 


'm- ' 


'  m.  -  i  ■ 


P.  h 


r 

i 
1 

1     !:^    ■ 


«£:     .j"! 


f  ! 


^ 


ii!  I  j 


■  i 

f 

|i! 

fii 


36 

tion  several  large  abscess  cavities  coiniminicating  with  each  other,  with 
ragged  walls  au'l  purulent  contents. 

Gangrene. — In  three  instances  this  termination  was  met  with.  Case 
LIV.,  female,  ret.  35  years,  a  hard  drinker,  was  admitted  with  pneu- 
monia of  the  left  lung,  which  had  existed  for  some  days,  during  which 
she  had  been  neglected  and  much  exposed  to  cold.  The  lower  lobe 
presented  at  its  apex  and  extreme  base  signs  of  consolidation,  but  in  the 
rest  of  its  extent  was  represented  by  a  large  gangrenous  cavity,  occupied 
by  shreddy  and  necrotic  lung  tissue  and  blood  ch)ts,  the  whole  forming 
a  stinking  mass.'  The  walls  were  not  defined,  except  at  the  lower  part, 
where  a  separation  between  the  sloughing  and  firmer  lung  tissue  could 
be  plainly  seen.  In  Case  LX.,  male,  a!t.  63  years,  with  pneumonia  of 
the  left  lung,  there  was  a  spot  of  gangrene  at  the  apex  surrounded  by 
dark  consolidated  tissue.  Case  LXXIV.,  male,  set.  50  years,  a  hard 
drinker  for  twenty  years,  was  adr;\itted  supposed  to  be  suflfering  with 
delirium  tremens  ;  had  had  convulsions  before  admission.  Rigidity  of 
muscles  of  arms,  coma,  and  death  thirty-six  hours  after  admission. 
At  apex  of  right  lung  was  a  gangrenous  mass  the  size  of  a  hen's  egg, 
surrounded  by  greenish-black  consolidated  tissue.  Suppurative  menin- 
gitis of  cortex. 

Fibroid  indurufion. — The  production  of  a  chronic — so-called  inter- 
stitial— pneumonia  from  the  ordinary  croupous  form  is,  perhaps,  the 
most  rare  termination  of  the  disease.  The  following  case  is  of  special 
interest,  from  the  fact  that  the  man  was  under  observation  almost  from 
the  outset,  and  the  induration  was  in  patches  and  in  an  early  stage : 
Louis  Phillippe,  xt.  58  years,  a  laborer,  was  admitted  with  cough  am! 
pain  in  the  side.  Had  a  chill  five  days  before  admission.  Temperatui'o 
101*^  F.;  pulse  106  ;  lespiration  26.  Expectoration  not  bloody.  Phys- 
ical signs  of  pneumonia  over  right  lower  mammary,  infra-axillary, 
scapular,  and  infra-scapular  regions.  During  the  first  ten  days  in  hos- 
jf/ital  patient  made  no  satisfactory  progress ;  temperature  ranged  from 
99°  to  103°;  he  was  heavy  and  dull,  not  delirious;  pulse  weak,  100  to 
120.  Defective  resonance  in  infra-clavicular  regions  on  right  side;  in 
mammary  region,  a  flat  tympanitic  note  ;  beliind,  absolute  dulness, 
feeble  blowing-breathing  ;  a  few  rales  on  deep  'ns])iration.  The  note 
over  right  mammary  was  markedly  tympanitic.  Patient  emaciating. 
No  heart  murmur;  very  little  expectoration,  nuico-purulent,  not  bloody. 
On  the  twenty-sixth  day  ho  had  a  chill,  and  the  temperature  went  up  to 
104^^.    No  change  in  ])hynical  signs.    Died  at  noon  on  the  twenty-seventh 

1  Specimen  in  museum  of  McGill  Medical  Faculty. 


87 

bathed  with  sero«3  luid  On  ;  '  ■'"'  ''''.  ^"••^■"'^'  ^^  -<'"-'  -as 
fbaturos  called  .fattentio^  i  e^,:r!r'"^  ^"^  ^^'^  ^^^''••"'  ^^"- 
a.r-cells  could  be  .seen  Mith  thoi,.  fi  ,      "'  '"  ''''^'''"  "^'^''™^  the 

character,  u„do>.,„i„;  IZ  ^  .'''T '  l^^^S^,  of  a  very  opa.ue  white 
able  areas,  ^e.^^^^;,  tlZt^^J^'  «  ate  existed  in  very  consider- 
-itb  Pu.,  and  break  „„.^;;,  l:":;''^'^^  "^-«  ^'-'-^y  '""Ifated 
tbese  was  about  the  si  Jo  T,  ,  ^^  il^^^'  ^'^  'arrest  of 
the  lung  there  were  .pots  wh    b        1  "'''-'''  '"  ''""''"''^  '^'''^^  ^f 

finn,  smooth,  hon,o,e,;^:  :  :    t.-':  j.;;.  ^^  ^'^TT^r  '•^^'^^^'  -- 
connective  tissue.     In  the.;  areas  a  fi.  '^  ""  ^"''^  '^^  '''^^' 

b.ng;  the  alveolar  wall   ";.X,l'r     f?""^:/"^  S^ing  on  in  the 
the  air-cells  were  underVoi  u!  f     '  ''•"'  ''"'  "^'"'"'^"^  P'"g^  «Jli"g 

nective  tissue.        ""''"'S'^'"^'  transformation  into  a  nc.v  growth  of  con 

^=^"thf;:r;;iu;^::^r'L^;r 

Mature  in  pneun.onia  autopsie  TI 'w  .  ''^-  ,"' •"  '"  '''^  ^""^^'-^"^ 
and  a  solid  .ould,  capped 'I^^Hy'^^.'fXh:  '^  ""''"^'  ''''  ^"• 
ronu.ved  with  the  extensions  into  the  cav^  a  ^  '  \'- "  ,'""''"""^'  ^" 
have  seen  a  complete  cast  of  f  1  I  .  '"'^'  ''^  '^'  branches.     I 

the  smaller  vesii:^::r:'n  1  T  hJ  tf  •  -^-•-.— -"  to 
hepatic  and  the  iliac  branche       Fro.n  T''"'  '^'^^'"' '"^^"'1'"^'  the 

be  witlulrawn  by  carefnl  n.l         >  P"l.nonary  artery  there  can 

vessels  of  n^^ii!:iz:':iz:T:' :^::::f:,  'r  '-''^-'-^  '- 

meet  with  such  solid  coagula-s  fi^  ^^'^  '  '''"'^' ^''V^''^ '''^^'^' ^« 
occasions,  when  I  di<l  not  know  H  an.l  hbrnmus;  and  on  several 

incisions  for  the  rig  Inb  1  "  ""IT  f  '"  ^""'  ^'^^^  ''''^'-'-''-T 
as  to  the  existencetf  p^t  :  :l^Tn  •  ""' ''  ""''"  '  '''''''  8"ess 
or  the  right  side  and    o     iZ'of  "f  '"'''"'''  ^'"  "'^'•"»«'  «tate 

possibility  tln.t  a  copi:™^,:L^;:^ 

chambers-and  I  have  in  seve  n  n  ^  "'•'  ''"'■'''  '^''  "^'^'•'"aded 
.estion.     In  extens^:  ^d  ^i     ^^n::: '  ^"^"^  "^^""  *'''^  ^^•^- 

area  n.ust  be  very  much  in  Z  \,       'T'^^''^'''  "^  ^''«  "'"""'^d 

greatly  increased.'  ^^tZt  '.^l  '"""•'  "^  *'^^  ^'^''^  -"tHcle 
the  collateral  oedema  whcl   we     ,  "'""    T  ^^•^I'^-'-'ts  of  Welch,' 

e"n,stances,  has  no  exS  c  f  I'  "  '""  ''"'^'"^  ""^'^''  ^^'^'^  ^'  " 
produce  puimona;:  ^^I::^!:  'l!-?  ~  *"  ^'^^  ^'^  ^'^'arly  that  to 

assure  must  be 


very  much  beyond  that  which  can  be 


•aised  to 
induced  by  the  cuttino-  off 


I)oint 
of  cer- 


'  Virchow'B  Aicliiv,  Ixxii. 


Vr  !■ 


H?  S 


3S 

tain  territories  of  capillaries,  however  extensive,  in  a  pneumonia.  Yet 
there  are  difficulties  in  tlie  way  of  explaining  the  oedeina  of  the  sound 
portions  of  the  lung  on  the  view  which  Prof  Welcl»  holds — viz.,  that 
the  left  ventricle  is  first  weakened  or  paralyzed  and  the  continued  action 
of  the  right  gradually  i)roduoes  the  engorgement  and  o'dema.  It  seems 
natural  to  think  that  the  engorged  right  ventricle  would  more  quickly 
fail  than  the  left,  which  is  rarely  found  so  full,  and  certainly  has  not  to 
bear  the  strain  and  tension  of  the  right  cluunber. 

The  left  chamhci's  usually  contained  coagula,  but  were  rarely  dis- 
tended, never  to  the  degree  often  met  v.ith  in  the  right. 

The  tricusj)id  orifice  was  frequently  found  dilated,  measuring  from  five 
to  six  inches  in  circumference. 

Turbidity  ami  moderate  fatty  change  were  sometimes  noted  in  con- 
nection with  the  heart  muscle.  The  endocarditis  will  be  considered  with 
the  complications. 

t'^pken:  Friedreich  and  others  have  called  attention  to  the  very 
general  enlargement  of  this  organ  in  pntnimonia.  The  normal  weight 
may  be  taken  at  about  170  grammes.  In  only  85  cases  was  the  weight 
over  200  grammes — the  heaviest,  in  Case  TjXXV.,  was  670  grammes. 
In  12  cases  the  weight  was  under  the  average;  in  Case  LV.  it  was  only 
72  grammes.  Usually  the  pulp  was  very  soft ;  but  in  4  cases  the  note 
is,  "  pulp  firm,  and  cuts  well."  In  many  cases  the  weight  was  not 
recorded,  but  the  note  entered  was  either  "  normal "  or  "  slightly  en- 
larged." 

Kidneys :  In  exactly  twenty-five  per  cent,  these  organs  showed  signs 
of  interstitial  changes,  being  hard  and  fibroid,  with  adherent  capsules 
and  often  small  cysts.  In  eight  cases  there  was  marked  parenchymatous 
swelling;  in  Case  XXIII.,  chronic  parenchymatous  nephritis;  in  Case 
XXV.,  amyloid  degeneration  ;  and  in  Case  XXXII.,  extensive  fatty 
changes  in  the  tubules. 

Otker  disease'^  and  injuries. — One  case  occurred  in  connection  with 
diabetes  and  one  with  erj'sipelas.  Three  cases  followed  injuries,  one  a 
burn,  and  one  came  on  in  the  course  of  a  carbuncle.  In  all,  the  pneu- 
monia was  fibrinous  and  lobar.  These  cases  of  "  contusion-pneumonia," 
as  i.itten  terms  this  form,'  are  very  interesting,  and  may  come  on  after 
slight  or  severe  injuries,  or  after  operations. 

C'ompUcdHons. — Pericarditis  occurred  in  five  cases.  In  two  there  was 
extensive  double  pleurisy  with  the  pneumonia.  In  one  there  was  endo- 
carditis as  well.  Except  in  Case  XCIIL,  a  portion  of  lung  contiguous 
to  the  pericardium  was  involved  in  each  case. 


1  Zuitsehi-ift  filr  klin.  Medicin.,  Bd.  v. 


i!l      I 


89 

literature  shows  that  the  «c      r  2"     'tl        "  '  r''"''  '  "^''^"  "^'  ^^'^ 
is  by  no  means  infrequent      In  ifi  f  '"'"''''"^"""  i"  pneun.onia 

ulcerative  fbr,n,  an<  he  ^.^"Z  Th  '"v"  '''""'^°'  "^•''^''^'  «^"  el- 
even „.asked  by  tin-s  con  p£  :^^  Ou  ^  T  ""  '""^^  '^^^"'•^'^'  ^ 
gestion  that  endocarditis  m  sf  Lr  ,  '  T  '"'  ^«"i'l^»''l'«  s^g- 
monia,  but  in  a  revi  of  H  ^1'  -'-PHeates  left-sided  pneu- 
cli-ase,a„din  whic^  el;'  r  .  ^"'^^^^''^'^'^  — ing  in  this 
it  -«s  in  the  ri,ht  l^etd  ^^^^ri^f  ^l'-'  """  ^"^^^  ^"  ^^ 
if  contiguity  has  anything  to  do  with  it  '    "  *^"'  '^  ^^""^  ^''^"'^^^"1 

Memnnitls:  In  8  psisp^j  tlin,.„  „ 

a™c,.„i.ii  a,..,  i„  2  r::„  ^  r  r'MrL'"""'-"-"',""-  ■-  ■  ->- 

ulcerative  endocarditis.    Bnef  deuil,  „     ,.    e  e  alVZ  b"'  ""'  *° 

Case  II.,  ma  e,  ;ct.  38  veara      K„,l  I         '"".'^^  ">»)'  M  given  : 
lung,  extensive  ixudatio^  Tl,„  „     f?'""^"!""'  °''  "I'P'''- '»'«  »'  rieM 
along  the  Svlvian  C'e  """'  '"  '""-■"■di'-a'  »i.."S  ,fnd 

wiS'::„a,fi!;eir;'i:;.-"?e'  't  "'^^  '■°"»«'-""™  °f '«"  i-s. 

hemisphere  c„  e  id  ^^^        e,"  " /""'"""f  "'°  """'  '""'-'"•'«" 
delacLed  in  flakes.     /„  Ivn  „l,  7    ,1   7°"'  '™^^-  "'''"■•I'  «""W  be 

Case  LXXXIV.,  ™,e  ":"  '  7e    /"X:";'"'"  7  °^  "'°  '"'*• 
»P|.or  lobe  and  a  spot  of  mmle      jj    '    l>epat,.ahon   of  right 
meninges  and  exudation  of  ifmT  ,  ,,,  e,e    '  °T'!'°"  '''"  ~'""»' 
Pital  loLos  ■  none  „t  the  b.nse  '  *"""■  ""=  '"'""'  »»'l  »«* 

.i-.i.  Mitral  „i;:: ; :  • ;  ,«aS-  Sf " '■;-"'1."°"'"  '"■■«  ''''- 

Endocarditis,  n^tl-    '     d'^t'it 'T  '     v'"',''f  "'  ''"''  '""'^  '"f-"-'''- 
exudation  of  i,,nph  otrr'tLfar  rS"      "'  "'°  '*  '"""■^^'---  -"' 
Ht  the  base  or  on  the  right  side 
Case  LXXXVII 


ni 


parietal  convolutions.     None 
iile.     Double  pneumonia;  right  apex.     Ulcer- 


I    i 


-F  ^  i ' ' 


III  it  j^ 


if 


40 


ative  ondocanlitis  of  mitral.     Cortical  nioiiingilis-.     No  lymph  at  the 
base. 

Case  XCIX.,  female,  ret.  19  years.  Red  hepati/ation  of  central  part 
of  right  huiy.  Endocarditis  of  anterior  segment  of  mitral  valve.  Menin- 
gitis of  corte.K — both  hemispheres. 

The  comj)lieation  of  meningitis  is  one  of  the  mo.st  serious  that  can 
occur  in  pneumonia,  and  it  would  ap})car,  in  a  considerable  proportion 
of  the  cases,  to  be  associated  with  ulcerative  endocarditis.  We  may 
suppose  the  intlammation  of  the  heart  and  the  meninges  to  be  induccil 
by  a  common  cause,  or,  what  would  apjjcar  likely  in  nnmy  cases,  the 
nicniugitis  is  embolic  in  origin,  for  it  also  occurs  in  malignant  endocar- 
ditis, unassociated  with  ])neumonia.  In  twenty  cases  of  meningitis  in 
this  disease,  only  fiftecMi  occurred  with  i)neumonia.  The  infective 
material  may  po.fsibly  be  derived  directly  i'rom  the  infiltrated  lung- 
tissue,  and  carried  off  by  the  pulmonary  veins.  We  know  that  occa- 
sionally large  cnd)oli  may  be  derived  from  this  source,  as  in  a  case  of 
pneumonia  occurring  at  the  (ieneral  Hospital  in  1879,  in  which,  during 
the  progress  of  the  disease,  and  not  associated  with  endocarditis,  there 
was  embolism  of  one  femoral  artery  and  gangrene  of  the  leg,  necessitat- 
ing amputation  above  the  knee. 

The  inilannnation  in  these  cases  is  almost  always  cortical,  and  the 
chief  symptoms  are  initial  delirium,  then  stui)or  and  coma,  sometimes 
rigiditv  of  the  muscles. 

Croupous  colilh:  In  Cases  HI.,  XX VIII.,  XLIL,  LXXXV.,  and 
XCIX.,  this  unusual  com])lication  was  met  with.  In  Case  III.  the 
csecum  was  covered  with  a  thin  layer  of  adherent  lynij)h,  and  scattered 
throughout  the  colon  and  sigmoid  flexure  there  were  numerous  elevated 
patches  of  lymph,  about  the  size  and  shape  of  rupia-crusts, "which  on 
section  were  found  firmly  attached  to  the  nuieosa.  In  this  instance,  the 
process  was  very  extensive  and  the  ]iatches  much  thicker  than  in  any 
subscfjuent  case.  iNIore  often  there  is  a  thin,  flaky  exudation,  involving 
only  the  surface  of  the  mucous  membrane.  In  none  of  the  cases  w..s 
there  ulceration. 

Croupous  f/adrUis:  In  Case  IV.  the  stomach  and  duodenum  were 
found  "  greatly  distended  with  gas.  The  mucosa  was  pale,  except  about 
the  fundus,  where,  just  to  the  left  of  the  cardia,  there  was  an  extensive 
area  of  croupous  intlamnuition,  represented  by  a  thick,  adherent,  grayish- 
white  exudate,  covering  an  area  12  by  8  cm.  Beneath  the  mucosa  the 
membrane  was  deeply  injected." 

This  paper  is  meant  to  be  merely  a  statement  of  facts,  a  record  of 
observations  upon  a  common  and  well-known  disease.     As  opinion  is 


still 


:^.    I 


41 

still  divided  as  to  the  ,c,cnoml  or  local  nature  of  pncuruonia,  it  is  intor- 

s.„g  to  note  how  strongly  the  evidence  iron,  n'orbid  anaton.y  t      L 

tonard  the  fonuer  view.     The  frequenoy  of  the  occurrence  of  various 

«ut.ve  .nfianunutions  finds  a  parallel  only  in  some  of  the  specific 

AVhile  this  paper  has  but  a  trifling  value  as  a  pathological  contribu- 
tion, to  he  writer,  as  d<,ubtles3  to  the  students  wlu,  perfor.^ed  the  a  - 
s.es  un.  er  lus  d.rect.on,  the  careful  study  and  observation  of  the  eas  s 
"Pon  winch  .t  has  been  based  have  been  of  ,he  greatest  service.  1,1 
.nvesfga  ,on  of  disease  a  knowledge  of  the  M,orI,id  phenon.ena  observe.l 
dunng  ,  e  .u,d  of  the  organic  alterations  found  altJr  death  are  inseri:;: 
.  )lc..  I  he  teaching  of  the  post-niorteni  roon.  must  supplement  and 
:    ustrate  the  lessons  of  the  wanl,  and,  as  Bichat  says,  it  il  neither  fCn 

f '  yir  '     '  '■""  ''''''  ''''''  "  '"  ^-^^'^'^^"^  l-^'-''>«-  "  -" 

April  23,  1885. 


!•  I 


■I' 


} 


i     H 


H 


2.  Asperr/i/f lis  from  (he  lung. 

The  specimen  was  sent  l>y  Dr.  Rogers,  of  Denver,  Col.,  with  the  folio w- 
...  history  :  "Mrs.  H.,  .t.  2!)  years.    In  Colorado  for  tw;  years.    Mo  h^ 
iK^o^  phthisis  when  patient  was  eight  n.onths  old.     She  i  a  robust  and 
ugoious  woman,  and  states  that  she  has  always  enjoyed  good  health 
When  seventeen  years  old  she  began  to  cough  up  bodies  shnilar  to  tl  e 
aocoinpanyng  one,  but  smaller,  at  intervals'of  about  three  months-nev 
..K>.-e  than  one  at  a  time,  an.l  it  was  generally  unbroken.    The  bo.lies  live 
gradually  increased  in  si.e,  and  the  intervals    have    become   si  o    er 
.•nt.I  now  the  attacks  recur  every  two  or  three  weeks.     The  bodies     ^ 
you  may  see  fron.  this  one,  are  now  of  the  size  and  shape  of  a  sma  1       '.i 
can,  and  present  a  soft  downy  outgrowth  on  all  sidc^  but  one,  wh 

a  little  ca  ity     1  he  color  is  of  a  light  gray,  but  dark  on  the  attached  side 

On  examination,  I  found  it  to  be  a  v,,getable  fungus,  and  send  it   o  ^^^^ 

for  more  accurate  determination.     Mrs.  H.  has  no    ou-h,  except  from 

o..e  to  three  days  before  one  of  these  bodies  is  expelled,;^!   t      fii  X 

broug^it  up  by  a  very  violent  cough,  and  she  descJibes  i   as  comin.  wi  h 

ome  force  into  the  larynx  against  the  vocal  cords,  where  it  som^t  me 

odges  unti    another  cough  expels  it.     Shortlv  before  it  conges        she 

has  a  'husky,' obstructed  sensation  on  taking  a  deep  bre    h  b      no 

hoarseness  or  marked   discomfort  of  any  kind!     For  a  short  time  she 

expenences  a  disagreeable,  musty  taste.  ^After  its  expul  im     ,    "Is  no 


I!     f 
) 


\ 

) 

1 

l' 

] 

p 

1'  ^ 

'!.     ^ 

.,      i      . 

H^-%- 


1 

1 

i  <1 


U    it 


m" 

J^  ll 

V^HB    f  ^     '             4j| 

^HH  M 

^^B  1E| 

IjuH  w' 

42 

furtlior  symptoms  until  tie  next  attack.  Ilor  luisl)and,  who  is  a  physi- 
cian, has  examined  the  Iiin;,'s  repeatedly,  and  can  (ind  nothing  ab- 
normal." 

The  specimen  contbrn;>  to  the  txcellcnc  description  of  Dr.  Rogers,  and 
on  examination  is  seen  to  be  made  up  almost  exclusively  of  the  myce- 
lium and  spores  of  an  aspcrgiHiis,  most  probably  A.  (jlaucm.  There  is 
no  portion  of  lung  or  bronchial  tissue  with  it,  or  any  mucus  or  adherent 
cells. 

Cases  of  so-called  i)neumonomycosis  aspergillina  are  rare,  not  more 
than  eight  or  ten  cases  having  been  reported.  The  literature  is  fully 
given  by  Furbringcr,  in  Virchow's  Archlv,  Ixvi.  The  majority  of  the 
specimens  have  been  discovered  post-mortem,  in  old  cavities  or  spots  of 
hemorrhagic  infarction.  The  points  of  special  interest  in  this  case  are : 
(1)  the  occurrence  in  a  woman  in  ai)i)arently  good  health  ;  (2)  the  re- 
markable duration  of  the  atiection  ;  and  (3)  tiie  recurring  attacks  of 
coughing  which  result  in  the  expulsion  of  the  fungus. 

October  8,  1885. 


Specimen  from  a  case  of  tuberculosis  of  both  lunrjs,  with  implication  of  the 
suprarenal  bodies  and  tuberculous  ulceration  of  the  colon— symptoms  of 
Addison's  disease. 

The  speo-'nens  exhibited  were  removed  from  the  body  of  a  gentleman 
38  years  of  age,  married,  and  by  occupation  a  piiysician.     Family  his- 
tory bad  ;  his  mother,  his  paternal  grandfather,  and  two  uncles,  having 
died  of  pulmonary  consumption.     The  patient's  health  was  fairly  good 
until  about  two  years  ago,  when  he  had  well-characterized  mild  enteric 
fever,  from  which  he  made  what  was  regarded  by  his  physician  as  a 
good  recovery.     He  did  not,  however,  fully  regain  his  strength,  and 
an  occasional  cough,  from  which  he  had  suffered  for  some  years,  began 
to  be  persistent  and  annoying.     He  was  able,  however,  to  resume  his 
usual  occupation.     During  the  spring  and  summer  of  1885  he  began  to 
lose  flesh  and  strength,  his  appetite  became  irregular  and  capricious,  his 
cough  more  troublesome.    The  cough  was  especially  annoyir.g  on  assum- 
ing a  recumbent  position  and  during  the  early  hours  of  the  night.     Ex- 
pectoration was  rare  and  always  mucoid  in  character.    He  suffered  from 
occasional  irregular  chills  which  were  regarded  as  malarial ;  night  sweats 
from  time  to  time  annoyed  him.     After  a  cold  f^ontrartcd  while  driviii'-'- 
m  September,  all  the  symptoms  were  aggravated  and  the  patient  began 
to  experience  more  or  less  constant  deep  pain  in  the  epigastric  region. 


48 


I 


llus  pan,  he  dcvsonhnl  a.s  of  a  toari„g  or  clrag.in.i;  kin.I  not  af,,rravato,l 
.V  iood  and  l.able  to  parox y.sinal  cxacerhationH  of  considerable  inte..sitv 
lie  now  noticed  that  his  complexion,  ahvayn  dark,  wan  l.ocn.in.^  deeolv 
and  somewhat   irregularly  pigmented.     About  ibis   time  he   be-an  to 
Bufler  from  occasional  vomiting,  f,,,-  which  no  cause  c.Mild  be  ascribed 
At  intervals  of  five  or  six  days  the  contents  of  the  stomach  were  thrown 
up  without  pain  or  distress,  and  e-jually  without  relief  to  the  ordinarv 
sympton.s  of  his  mahuly.      The  bowels  were  moved  with   renmrkable 
regularity  once  a  <lay,  the  evacuations  being  fluid  an.l  conlainin.-  sM.all 
sponge-bke  n.assos.     The  urine,  upon  repeated  exan.inati.m,  yiekled  no 
trace  either  ot  albumin  or  sugar.     Notwithstanding  his  growln-^  weak- 
ness ami  suHerings,  the  patient  delivered  a  course  of  lectures" In  the 
insftut.on   viib  which  he  was  eonnecte.l  during  the  winter,  an.l  devoted 
some  hours  each  day  to  literary  work  In  addition  to  the  dischar^^e  of 
other  professional  duties.    In  March,  however,  he  completely  broke  down 
and  came  to  tins  city  for  treatment.     The  appearance  of  the  patient 
when  he  hrst  came  nndcr  observation  here,  was  that  of  well-ma,-ked 
Addison  s  disease.     The  face  Avas  deeply  pigmented,  the  discoloration 
bcmg  more  marked  about  the  brows,  eyelids,  and  lips.     T1h>  mucous 
n.enibranc  of  the  mouth  was  but  slightly  afiected,  the  hands  were  much 
discolored,  the  finger-tips  clubbe.l,  the  nails  ineurvated,  the  bo.lv  and 
imibs  wore  also  much  discolored,  especially  about   the  flexures  '   The 
pigmentation  over  the  site  of  a  former  blist'er  and  in  the  neighborhood 
of  an  old  injury  near  the  left  knee,  was  peculiarly  intense 

Aiuemia  was  of  moderate  .legree,  the  numbe;-  of  red  corpuscles,  as 
counted  by  Dr.  Osier,  being  4,200,000. 

The  patient  suHered  from  a  sense  of  great  Aveakness,  which  was  in- 
creased an.l  accompanied  by  dyspna.,  and  faintness  upon  exertion  His 
mental  ondition  was  clear. 

The  clinical  phenomena  relating  to  the  digestive  system  remaine.l  the 
same,  with  the  exception  that  the  appetite  curiously  increased  during 
the  last  weeks  of  the  patient's  life.  ^ 

The  imlmonary  symptoms  grew  rapidly  worse.    Physical  examination 

vealed  du  ness  ,)ver  the  upper  lobe  of  both  lungs,  more  marked  and 
more  extended  on  the  left  side.  There  were  also  feeble  bronchial  respira- 
tion and  occasional  crepitant  and  subcrepitant  rales. 

The  heart's  action  M-as  regular,  90-110  per  minute,  very  feeble- 
there  were  no  adventitious  sounds. 

The  area  of  liver  dulness  was  somewhat  increased;  that  of  splenic 
duliiess  \vas  normal.  hp'^nc 

The  abdomen  was  neither  distended  nor  retracted  ;  it  was  resonant 


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44 

upon  |)orciis.^i()n,  witb  tho  cxcoptiun  of  ii  Ilmitod  area  in  tlie  left  iliac 
region,  wliorc  there  was  dinunislud  tympany  iiinl  Home  ohseiire  resist- 
ance on  palpation.  These  signs  were  atterwanl  ioiind  to  orrespond  t„ 
thiekening  ,d'  the  colon  und  enlargement  of  the  glanduhe  epiplcicio  in 
the  reiiion  of  an  nleer. 

TiK're  was  slight  epigastric  tenderness  upon  pressure.  Death  took 
pluee  May  '22,  l.s,S(5. 

A  i(l<>/<.v/,  ih!rty-»lx  hours  after  </«<///.— ^[oderatc  eniaeiation.  Pigmen- 
tation not  so  deep  on  trunk  as  it  was  some  weeks  before  death  ;  on  fuc,. 
quite  as  intense. 

In  (ilubmni,  no  chronic  peritonitis;  membrane  not  dark  colored,  h. 
the  course  of  the  coh.n  were  several  thickened  and  congested  portions, 
one  of  which,  about  tin-  nuddle  of  the  sigmoid  (lexurerwas  very  lirm.' 
and  the  appendices  epiploicie,  and  adjacent  mesocolon  were  greatly  en- 
larged. There  were  several  calcified'  lymph  glands  iu  the  "nesentery. 
Branches  of  portal  system  moderately  full. 

In  //(o/v^r  universal  adhesions  on  right  side ;  on  left,  at  apex  and  pes- 
tero-lateral  regions. 

Heart  of  medium  size ;  chambers  contained  dark  clots.  Valves  jiornial. 
Muscle  i)ale.  and  showed  fatty  changes. 

Luuri..:  Upper  lobes  extensively  diseased,  and  in  great  part  airless. 
Section  showed  many  group.^  of  tubercles  in  a  Hbroid  and  pigmented' 
tissue.  Here  and  there  a  small  caseous  nodule.  No  cavities.  The 
8n)aller  bronchi  a  little  .lilaied.  In  the  left  lung,  one  nf  the  large 
bronchi,  passing  to  the  apex,  was  jilui;  .ed  with  iirm,  cheesy  matter. 
Between  the  groups  of  indurated  tubercles  and  at  the  marLniis  the  tissue 
was  emphysematou,s.  The  process  was  most  advanced  in  the  left  lung. 
In  the  middle  lobe  of  the  right  and  in  the  lower  lobes  there  were  a  few 
groups  of  firm  tuliercle. 

Splrca  of  normal  si/e,  and  presented  scattered  cheesy  tubercles,  with 
firm  capsules. 

Stomach:    Extensive   post-mortem   solution    at  cardiac  end   and   in 
oesophagus.     Mucous  membrane  pale;  veins  full. 

Panvrem  healthy. 

Dmdi'nam  normal.     Bile-ducts  pervious. 

Small  nih.tine  presented  a  few  small  tubercles  in  Peyer's  patches,  but 
no  loss  of  substance.  In  large  intestine  five  large  areas  of  ulceration, 
evidently  of  long  standing,  as  the  bases  of  the  ulcers  were  cicatrized,  and 
in  on.  or  two  the  calibre  of  the  bowel  was  reduced. 
^  Kidiiefjs,  suprarenals,  and  aorta  removed  together  for  dissection.  The 
tissue  between  the  coeliac  axis  and  the  head  of  the  pancreas  was  puckered 


46 

by  tlic  presence  of  throe  or  four  calcified  lymph  yliitulrt.    The  left  sphinch- 
nic  nerve  ent(«re<l  a  hir-,'e,  normiil-kjokinK  scniihinar  j,'an,i(Iion,  circular 
in  form,  which  oinhraccd  a  small  acccs.sory  suprarenal  ahout  the  size  of 
a  pea.    The   ri-lit  splanchnic  passed  to  a  snmller  uan-liun,  which  also 
looked  normal.     There  was  no  "niattinir"  or  thickenin-  about  these 
bodies,  and  the  nerves  passing'  from  them  could  be  readily  traced.    Just 
to  the  rigiit  of  the  cadiac  axis  the   tissues  wen;  a  little  matted.     The 
8uprar(mal  cai)sulcs  were  small  and  Hat,  and  had  lost  the  normal  shape. 
The  left  seemed  lower  than  usual,  and  was  separated  by  a  distinct  inter- 
val from  the  kidney.     It  presented  two  linn  cheesy  masses  which  occu- 
picl  the  .uM-cntcr  portion  of  the  -land.     In  the  thinner,  peripheral  parts 
remnants  of  cortical  substance  could  be  seen  as  small  islands  of  yellow- 
brown  tissue  ind)edded  in  a  j^ray  fibrous  stroma.     The  ri^ht  ^r|.„"„l  \va9 
flatter  and  thinner,  puckered  on  the  surface,  and  presented  n".  trace  of 
normal  tissue.^    A  lar-re,  flat,  cheesy  nuiss  occu|)ie(l  the  greater  part  of 
the  orjran.     The  kidneys  were  large  but  normal;   veins   full.     :\Iicro- 
scopical  examination  of  the  capsules  showed  tubercle  bacilli  in  scrapings 
of  the  cut  surface.    Tlu^       •  ion  presents  the  usual  character  of  the  fibro- 
caseous  chancre  so  ofU  .1   acscrihed  in  these  inlands.      There  was  also 
marked  atrophy  of  the  cortical  rej,don3,due  apparently  to  an  increase  in 
the  interstitial  tissue.     The  nerves  ]r.imn'^  to  the  <,dands  and  the  semi- 
lunar gan-lia  presented  no  essential  changes.     There  w*as  the  usual  pig- 
mentation  of  th'- nerve  cells.  May  27,  lAHii" 


The  hcvmatozoa  of  malaria.  • 

Our  knowledge  of  the  animal  parasites  infesting  the  blood  has  been 
of  late  enriched  by  observations  which  show  that  certain  of  these 
hfematozoa,  as  they  are  called,  are  more  widely  distributed  and  more 
important  than  we  had  hitherto  supposed.  Parasites  belonging  to  the 
sporozoa,  and  to  the  nematode  and  tromatode  worms,  have'' long  been 
known  to  occur  in  the  blood  of  various  animals.  Recent  investigations 
prove  that  the  flagellate  protozoa  are  also  not  uncommon  blood  parasites, 
and  it  is  possible  that  they  may  be  the  pathogenic  organisms  of  certain 
diseases.  I  propose  in  this  communication  to  give  an  account  of  the 
hiematozoa  which  have  been  found  in  persons  suffering  with  the  various 
forms  of  malaria. 

lEstonml.  -Our  knowledge  of  the  blood-changes  1  am  about  to 
describe,  dates  from  the  researches  of  Laveran,  in  Algiers,  which  were 
communicated  to  the  Paris  Academy  of  Medicine  in   1881  and  1882, 


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and  which  were  finally  embodied  in  a  large  work  on  the  malarial  fevers, 
published  in  1884.'     He  found,  as  characteristic  elements  in  the  blood  of 
persons  attacked   with  malaria,   (1)   crescentic  pigmented   bodies;  (2) 
pigmented  bodies  in  the  interior  of  the  red  corpuscles,  which  underwent 
changes  in  form,  described  as  amoeboid  ;  and  (:])  a  pigmented  flagellate 
organism.     These  forms  were  looked  upon  as  phases  in  the  development 
of  an  infusorial  organism  wiiich  he  regardeil  as  the  germ  of  the  disease. 
Richard''  coniirmed  these  observations.     A  more  general  interest  in  the 
question  was  aroused  by  the  publications  of  Marchiafava  and  Celli,'  who 
fouud  in  the  blood  of  malarial  patients  at  Rome  the  bodies  described  by 
Laveran.     They  figured  carefully  the  alterations  of  the  organism  in  the 
interior  of  the  red  corpuscles  to  which  they  gave  the  name  Plasmodium 
malariie.     Councilman,  of  Baltimore,  has  more  recently  confirmed  these 
observations.*     The  pigment  granules  so  numerous  in  the  interior  of  the 
red  corpuscles  in  cases  of  "  comatose  pernicious  fever,"  which  appear 
to  be  included  in  a  hyaline  mass,  are,  according  to  Marchiafava  and 
Celli,  and   Councilman  (who  had   previously  described  them^),  these 
amojboid  parasites  deeply  laden  with  altered  hiemoglobin. 

Technical  dcfml>i.— The  finger  pad  from  which  the  blood  drop  is  taken 
should  be  thoroughly  cleansed,  and  if  the  examination  is  made  during 
a  paroxysm,  the  sweat  which  may  exude  after  the  friction  and  drying 
should  be  removed.     Attention  to  these,  apparently  trivial,  details  will 
secure  specimens  of  blood  free  from  small  particles  of  dirt,  and  facilitate 
considerably    the   search   for  pigmented    bodies.     The    layer  of   blood 
beneath  the  top  cover  should  be  very  thin  and  uniform,  the  corpuscles, 
as  far  as  possible,  isolated  and  not  aggregated  in  clumps  or  in  rouleaux. 
It  is  well  to  surround  the  cover  with  paraffin  if  the  exumination  is  pro- 
longed.    No  reagent  of  any  kind  should  be  added.     Cover-glass  jjrepara- 
tions  may  be  made  and  stained  in  methyl-blue  or  fuchsin,  and  mounted 
in  balsam.     Osmic  acid  preparations  may  also  be  employed.     Although 
these  bodies  may  be  seen  with  a  power  of  500  or  (JOO  diameters,  it  is 
essential  for  the  satisfactory  study  of  the  changes  to  use  higher  powers. 
I  have  unifoii.ily  worked  with  the  j\  homo,  immersion  of  Zeiss,  and  the 
yV  im.  of  Ri'ichert.     Strieker's  warm  stage  wOl  be  found  useful. 

Desciui'tion  of  the  Bouriis.  1.  The  forms  which  exid  wilhin  the 
red  corpuscle— (a)  The  most  common  alteratioiF in  the  blood  of  malarial 
patients  is  presented  by  a  pigmented  structure  inside  the  red  corpuscle. 


'  Tniito  (los  Fii'vres  Piilustres,  Piifie,  1884. 

2  CuMipti'sliciiiliis,  1N«2.  3  Kortschritto  dor  Modicin,  Nos.  14  and  24,  1885. 

<  l'u|icr  rend  iii'fDie  tlin  Associiition  of  Anic-iciiM  Pliyslciiina,  June,  1880, 

6  Coiiucilniiin  and^bliul:  Ainoiicau  Journal  of  the  Medical  Scionoea,  April,  1885, 


^i\'- 


47 

The  attention  of  the  observer  will  most  likely  be  first  attracted  by  the 
presence  of  a  few  dark  grains  in  the  stroma,  and  a  careful  study  of  a 
suitable  specimen  will  soon  lead  to  the  conviction  that  the?o  are  not 
scattered  loosely,  but  are  enclosed  in  a  finely  granular  or  hyaline  body 
m  the  interior  of  the  corpuscle  (Fig.  1).     The  red  disks  in  which  they 

FlQ.  1. 


■i.  1       ifMI-        ! 


Ameboid  body  in  red  blood-corpuscle..    Th.  .K-tchoB  were  n.ade  at  intervals  of  five  minutes. 

occur  are  usually  larger,  look  flat,  and  are  verv  often  paler  than  normal  • 
they  may  indeed,  exist  only  as  colorless  shells.     The  number  of  corpuscles 
so  afTectcd  varies  extremely  in  different  cases.     In  some  instances  they 
are  readily  found  after  a  search  of  a  moment  or  two,  but,  in  other  cases 
a  prolonged  examination  may  be  necessary.     Only  one  is  usually  present 
111  each  corpuscle,  out  two  or  three,  or  even  four,  may  occupv  the  stroma, 
lliey  vary  greatly  in  size,  the  smaller  ones  not  occupying  a  fourth  of 
the  corpuscle,  while  the  larger  ones  may  almost  fill  it.     A  delicate  con- 
tour line  can  usually  be  seen  separating  the  body  from  the  stroma;  at 
imes  this  ,s  very  indistinct,  particularly  if  the  illumination  is  very 
briglit.     I  he  substance  appears  hyaline,  or  very  finely  granular,  and  the 
pigment   grains   are  scattered  irregularly  in  it.     They  may  be  very 
numerous,  and  give  a  dark  aspect  to  the  body,  or  they'niay  be  scanty, 
lliey  fre(,uently  present  rapid  Brownian  moven)ents.     Occasionally  a 
yacuole  may  be  seen  in  the  interior  of  the  body.     In  several  instances 
the  bodies  appeared  to  be  enclosed  in  a  clear  space-vacuole-in  the 
sroma.     When  first  seen  they  are  more  or  less  spherical,  but,  as  already 
stated,  the  outline  may  be  indistinct.     The  pigment  granules  may  be 
seen  to  alter  their  position  in  relation  to  each  other.     If  the'mar..i„  of 
he  body  IS  carefully  observed,  slow  changes  can  be  seen,  whicirgracfually 
bring  about  alteratioi.s  in  shape.     These  movements,  which  appear  to 
be  amoeboid  in  character,  can  often  be  traced  with  great  ease.     They 
are  well  represented  in  Fig.  1,  and,  better  still,  in  Fig.  2.     Changes  in 
position  of  the  body  of  the  corpuscle   result   from  them.     They  are 


r'ff1;ir; 


i    r       ■  1 


\  if 

■  h^          1 

:  f  1  '  j 

■■'f'i  ''  i 

48 


decidedly  slower  than  the  uinocboid  movement  of  the  colorless  corpuscle. 
I  have  not  seen  any  evidence  of  migration  from  the  corpuscle.     In  dry 


Fia.  2. 


■  Case  Vr.  Pigmcntod  liuily  in  rod  blooil-cui'imacle ;  outlined  with  camera  (1-12  Zeiss,  C  eye-piece),  by 
Dr.  J.  P.  C.  Grillitli ;  illustrating  some  if  tlio  cliangoa  during  aii  liour  and  a  Imlf's  observation,  a,  at 
11.45,  slow  aiterations  in  outiiue,  and  tlio  piguijnt-grauules  are  in  active  dancing  motion,  in,  12.1.5. 
an,  12  25,  body  has  rotated  as  well  us  altered  its  sluipo.  oiii,  12.30.  o[v,  12.40.  av,  1  o'clocli. 
OVI,  1.02. 

preparations  the.se  bodies  stain  deeply  with  gentian  violet  or  fuchsin  and 
present  a  granular  stroma,  in  which  the  pigment  grains  are  imbedded 
(Fig.  3.) 

Fia.  3. 


Cover-glass  preparation  of  blnod  stain-l  with  fuchsin.     Tlio  amneboid  bodies  stain  deeply  in  tlio 
corpuscles.    Soino  of  thom  are  not  pigmented. 

(b)  In  seven  cases  peculiar  hyiUine  structures  existed  in  the  interior 
of  the  red  corpuscles,  which  differ  from  the  bulics  just  described,  in  the 
absence  of  pigment  and  in  the  much  greater  activity  of  the  changes. 
Fig.  4  illustrates  the  appearance  and  the  alterations  in  outline.  These 
bodies  are  devoid  of  structure,  and  the  corpuscles  in  which  they  are 
present  are  not  so  pale  as  those  with  the  pigmented  forms.  Marchiaiiiva 
and  Celli,  who  have  given  an  excellent  plate  of  these  bodies,'  regard 


>  Fortechrltte  dor  Mcdiciu,  No.  24,  1885, 


49 
them  as  the  initial  forms  of  the  pl.^meuted  bodio,      n      , 

Fio.  4. 


»cre,  at  3.10  p.m     tL  lvalin„  ,      ','' '"  "  ''"^  "'Puocle,  tiiere 

changing  rapid,,  i ,  oliSe'T'?- -'"'"''   ''°"'"'  "'''""  -- 

fnlly  »atcl,i„g  these  form,  the  Z^«!l  ^  ,^  "'"■■ '"  '  »""  ««■ 
exit  to  two  distinct  .nasse,  e,r  S  w  ^  f'^'  '.""'"'■«'-  -^  Save 
spherical  bodies.    No  elmn^e  tool      I  u     "^ '"'°  "'"  "'■  «"«1™ 

except  that  theybecaJe  ,  ,1  and  i  sTi„:  "^  '?'  '"'='"  '«-- 
pascle  beeame  quite  colorless     On  twnl  °"'°'""  "f  "«  c™" 

c„„n  ™  witnessed,  b„t  r„„e^:,      „  frAT'"''' » ^^^  l"--™- 

'-""erial.  This  is  cvidcntlv  a  p  "si  ,„  '  '"'  r?",'"  "'°  """'"^ 
pale  hyaline  bodies  m„st  be  caie  llldl  "  ',  !,  '  "''"'<  ""^o  ™ry 
fonns,  though  possibly  Joeir     ,  ,,'  ^  ^^t^l  ''■°;"  "'=  "«-'««^ 

(c)  In  seven  eases  there  were  vae  ,oUi^H-V      "'"'""""■ 
-li.Mookiug  bodies  of  variols ir,  r^cT:"""'? r"'""""''' 

taves  rescnbled  u.i=r„eoeci  very  closelv    F      5)  ?,     "'         T  *"'=• 

J  v-i  io-  '-»;,  and  stained  deeply  in 

t'XG.  5. 


Covor.e,a,s  preparation,  showing  co,,„.c,e  with  soli,,,  deeply  st,.i„eH  h   r      ■ 
.,.  ,  ,  '        '  -^  "'"'""^  l""''™  m  small  vacuoles 


,,„;i;„„    1  , ^-"  "•""^  m  small  vacuoles. 

"^^:^:^Ji:^;  Zz  t:r  '""-*■  »■-  ■•-•■  -^ 

ones  were  usually  l,i,.|,ly  "f  °  t  if  "''f ""°«  '  "'»•  «'•    Tlw  sumller 


'  W^  rV' 


I' I    '■  ■  I 


,  I 


t^^  i 


***!    ii-i  P    ^1    -i 


■!  !  }  !|    J 


50 

had  a  deep  brown  tint,  as  if  composed  of  pigment.  The  larger  bodies 
were  bomogeneoiis,  very  variable  in  size  and  shape.  No  movement  was 
noticed  in  them,  but  the  outlines  of  the  ^rdccs  in  which  they  lay  some- 
times changed  actively.  In  Case  XXIX.  these  bodies  were  very 
abundant,  and  for  days  formed  the  only  noticeable  alteration  in  the 

corpuscles. 

Flo.  0. 


1,  li,  3,  hirgor  solid  bodies  in  the  interior  of  vncnoles  (?)  wliicli  nltor  in  outline.    4,  a  red  corpuscle, 
with  a  small  vacuole  containing  small  pigment-granules  of  a  deep  hrown-red  color. 

2.  The  free  forms. — ((t)  Pigmented  crescents.  These  bodies,  which 
were  found  in  eighteen  cases,  present  remarkable  features  in  appearance 
and  structure.  The  form  was  usually  that  of  a  beautiful  crescent  (Fig.  7)> 
with  rounded  or  gently  ta{)ering  ends;  but  the  degree  of  curvature  was 
variable,  and  many  forms  were  almost  straight.  The  length  is  about 
double  that  of  the  width  of  a  red  corpuscle,  sometimes  more.  They  are 
not  attached,  and  they  never  show  any  motion.  Joining  the  ends  of  the 
crescents — or,  more  correctly,  at  a  little  distance  from  the  points— a 
narrow  line  can  often  be  seen  on  the  concave  margin  (Fig.  7,  e).  The 
body  of  the  crescent  appears  made  up  of  a  structureless,  homogeneous 
material,  in  the  centre  of  which  is  a  prominent  collection  of  pigment 
granules.     This,  with  the  peculiar  form,  makes  these  bodies  very  easily 

Fio.  7. 


I    I     I 


c:::^:::^. 


yC^^ 


CrcsceutH,  a,  (>,  <■,  show  the  slow  ullerationH  in  the  form  of  the  pigment,  as  sketeliod  at  9.20,  10.40, 
ar.d  10.55  a.m.     *,  shows  the  narrow  nuMubrane  sometimes  present  in  the  concave  side. 

reccgnizable  in  the  blood,  even  when  closely  surrounded  by  the  corpuscles. 
The  pigment  is  very  dark  in  color,  distinctly  granular,  and  varies  some- 
what in  its  arrangemt-nt.  As  a  rule,  it  is  central  and  aggrcgared,  either 
in  a  hea[),  or  assumes  the  form  of  a  band  placed  transversely  to  the 
axis  of  the  crescent.     In  some  instances  it  is  more  scattered,  but  I  have 


61 

never  seen  it  at  either  end  of  the  horlv      a  ui        i     , 

»•»(!,  A  3).    A  c,-«co„t  became  witliin  ■„,  l,„„r,  „„  „;„a 

-Pia.  8. 


ni 


-ill 


Se  of  tie?  Zi^t  r  '-V  "  ^';^''  ""^  ^  ■^''  ''■''  ^••-     The 

and  rounded    bruff  iLJr'',     .""  "'  ''"""'•     ^^'"^^'  ^^-^'^ted, 

crescent,  prodon  inJt       T^         f        "'"  ""  ^'^'^  '"^^  ^^''^h'  ^"'  the 

Blide,  to  sil  or      "h    in    tt    "n    .■  ^f  "V"'''*''  ^'"'"  ''''  ^  *-^  '»  ^ 
'  ui   cign^  in    the  field  of  the   1-1'^th   im      Tl.  ^,.   i      i 

always  fl-eo,  they  „ce„r  sometime,  in  the    nter  or  Tf' .  °   ,      "'"" 

"«io  1.^:::;::  :r;i'::  :t:%T'  --^  ™-^'"  ""'"-^ » 

i"  the  eentre  a  ,«ette  ofX"™      Fi,!  '^  "''>,-™""  ^  I"-'""!''"'"',  ""d 

^^  ^■■*"'' '---^.Xa'JJrotLtrief  ^\:'r'it 

Fig.  9. 


Rosette  form:  1  freo-  2  u-ithi,,  f      i    .,    „ 

"eo,  J  ,Mth,„  t^o  Bhell  of  a  rcl  corpuscle. 


«::*:;:  r"  r™ : , :  "■«%r»' »' "-  ---  -f  «gme„ta. 

'l.e  finely  mn„l,„  ^Z^^    t  » ''o'      "1'°":  "''  -S'"™""-"  i» 


•' 

1  ■  ■ ', 

a' 

. '  '  i  ■ 

i 

i's 

1 

'<    Ih 

at  or  about  the  centre.  At  10.40  they  had  not  undergone  any  material 
change.  In  Case  LX.,  one  of  quartan  ague,  this  phenomenon  was  re- 
peatedly observed.  The  devehipment  of  the  rose  ..e  form  can,  I  think, 
be  traced  from  the  intracelhihir  pigmented  bodies,  wliicli  increase  in 


Fio.  10. 


Sognientation  of  a  rosette  form  ;  a  at  6  p.m.  ;  h  at  6.10,  sogmontaUon  proceeding  ;  c  6.30,  segmeutation 

complete  ;  </  7.40,  8iiiull  free  budiea. 

size  until  the  entire  corpuscle  is  filled.  In  some  instances  the  body  was 
surrounded  by  the  remnant  of  the  red  corpuscle,  in  others  there  was  no 
trace  of  it.  The  pigment  granules  gradually  collect  in  the  centre  of  the 
body  in  a  more  or  less  distinct  rosette.  I  thought  these  changes  had 
been  overlooked  by  the  writers  on  this  subject,  but  I  find  that  Golgi' 
has  given  a  very  full  description  of  them,  and  has  beautifully  figured 
the  development  of  the  rosette  form  from  the  intra-cellular  pigmented 
bodies.  He  has  followed  the  process  of  segmentation  with  much  greater 
detail  than  I  have  been  able  to  do. 

(c)  Flagellate  organ'mns. — Two  or  three  years  ago,  when  I  first  read 
Laveran's  papers,  nothing  excited  my  incredulity  more  than  his  descrip- 
tion of  the  ciliated  bodies.  It  seemed  so  improbable,  and  so  contrary  to 
all  past  experience,  that  flagellate  organisms  should  occur  in  the  blood. 
The  work  of  the  past  six  months  has  taught  nic  a  lesson  on  the  folly  of  a 
scepticism  based  on  theoretical  conceptions,  and  of  preconceived  notions 
drawn  from  a  limited  experience.  Fhigelhite  bodies  were  seen  in  seven 
cases,  never  in  great  numbers,  usually  only  one  or  two  in  a  slide.  Tiiey 
are  smaller  than  red  blood-corpuscles,  often  not  more  than  half  the  size. 
A  specimen  in  one  case  was  equal  in  one  diameter  to  a  red  corpu.scle 
lying  near  it.  They  are  round,  ovoid,  (n-  i)ear-shai)ed  ;  the  j)rot()pla.--in 
finely  granular,  and  in  every  instance  contained  pigment,  usually  cen- 
tral, which  often  displayed  rapid  Brownian  movements  (Fig.  11).  The 
flagella  are  variable  in  number ;  one,  three,  and  four  were  noted  in  dif- 
ferent specimens.  Tiie  length,  as  close!^  as  could  be  estimated,  was  two 
or  three  times  that  of  the  body.  They  are  exceedingly 
tapering,  and,  except  in  one  instance,  I  could  not  determine 


delicate,  gently 


'  Sulla  lufezione  Miilarica,  .\rcliivio  per  lo  Scioiizo  Mediclie,  vol.  .\.  No,  4,  1880. 


V^      III 


58 

"y  tne  pjay  ot  the  filament  over  the  surface  of 
Fia.  11. 


Flapollate  forms. 

LutlcouM  not  determine  wh«  became  rf  then   Th™  °^*""''''"'. 
free-s,vi,„mi„g  „i„a  deseribsd  by  W.U,  b  t X  .  ,  "°'  T  "'" 

that  he  ha,  confirmed  this  observat  o ,  I  h ,  "  ■,^°""';'''»'"'  «"«  -e 
either  nuc.eu,  or  vacno.e,  in  T^:^n^Z:l^"^X:"-"'°T 
change,  ,n  outline  occnr.  dae  to  slow"  m„„en.enr       be  p  ?  ' Zf  ""^ 

t^ubci.,  were  not  uncommon  in  some  cases  (Fig.  12). 


Fio.  12. 


© 


©-(9 


®® 


small  free  pigmented  bodies,  some  of  w.ic,  sl.w  am.boia  movements. 

of  subdivision  ot-rrosetter'n     ^""  '^'""  ^^^"'^'  "^  ^'^«  ^^^  ^-^'-'s 

Ihered  corpuscles  showed  nootlier  n..f,hlp  ..if      *•     "'P"=\'^*- 
described.    The  niP-mpnfpH  .  ,       ''''^''^^^•«"  save  that  already 


f'i   ill 


i9*  I 


If'  1 


, 


,.^!H 


r)4 

ical,  and,  finally,  are  reduced  to  the  condition  of  mere  shells;  except  in 
cases  of  pronounced  anaemia,  the  variations  of  the  corpuscles  in  size  and 
outline  were  not  great.  The  colorless  corpuscles  were  in  some  cases 
increased  in  number,  and  in  very  many  instances  contained  dark  gran- 
ules. In  several  specimens  they  were  observed  to  contain  the  pigmented 
organisms.  In  Case  XL.,  a  cresceh  had  been  included  (Fig.  13),  and, 
in  Case  LI.,  the  process  of  inclusion  of  two  free  pigmented  bodies  was 

Fi(i.  13. 


it\ 


A  colorless  corpuscle  containing  u  crescent, 

watched  during  half  an  hour.  The  blood  plates  were,  as  a  rule,  scanty, 
even  when  the  anaemia  was  pronounced.     No  pigment  was  seen  in  them. 

Types  of  mahiria  dudled. — Of  the  seventy  cases  examined,  a  majority 
were  instances  of  ordinary  intermittent  fever,  chiefly  quotidian  and  ter- 
tian, with  two  quartan  cases.  There  was  one  case  of  remittent  fever,  one 
of  comatose  pernicious  malarial  fever,  and  the  remainder  were  cases  of 
malarial  cachexia  or  chronic  paludism,  with  occasional  outbreaks  of 
fever,  with  or  without  chills.  In  all  of  the  cases,  with  the  exception  of 
seven,  one  or  other  of  the  forms  above  described  was  found  in  the  blood. 

Relation  of  the  forms  to  the  varieties  of  inahtria. — The  pigmented  amoe- 
boid bodies  are  met  with  in  acute  and  chronic  cases,  but  they  may  be 
said  to  be  specially  characteristic  of  the  more  acute  manifestation  of  the 
disease.  In  recent  examples  of  quotidian  or  tertian  ague  which  had  not 
been  under  treatment,  the  amoeboid  intracellular  forms  were  almost  in- 
variably present.  I  will  refer  subsequently  in  detail  to  the  cases  in 
which  they  were  not  found.  The  hyaline  non-pigmented  forms,  and  the 
vacuoles  containing  solid  bodies,  also  occur  in  the  acute  cases ;  indeed, 
these  latter  forms  were  the  only  alterations  noted  in  several  instances. 
Thus,  in  Case  XXIX.,  a  man  aged  48  was  admitted  to  the  Philadelphia 
Hospital  September  27th,  in  a  chill.  He  had  had  a  paroxysm  ten  days 
before,  and  had  suffered  with  malaria  several  years  previously.  The 
blood  examined  during  the  hot  stage  showed  no  pigmented  bodies,  but 
numerous  corpuscles  containing  the  vacuoles  shown  in  Figs.  5  and  6. 
The  chills  occurred  on  the  'iSth,  29th,  30th,  and  October  1st ;  and  each 
day  the  blood  was  carefully  examined,  without  finding  other  bodies  than 
those  in  the  vacuoles  or  hyaline  spaces.     On  October  1st,  the  patient 


instances  tlie  attacks  were  reccnt-.nwW  .,  n  .7  ' .  ''".'""''''•  ^^  ^'^ 
those  cases  ,,„iuine  had  bee  td  en  is  1  n  1  V'  '  '"  ''^'"^  "''^  '' 
alone  in  the  bloo.l  •  hnt .  ,       '^^'  ^^'^  crescents  occurred 

a.n.hoM  tl^      ,;;  :   nr .:;;- ;^--;^  i-  -'-•>  the  pi,n.nted 

six  weeks,  antemic  -md  hnd  -,  ).,,.         ,  ^^^^VII.:  quotidian  for 

off,  for  si.  „.ed<,,  t„e„  .o,.,«, ;  „,;,:•.„  •,;,^,       /'^  X^'cl:  ;  T 

"K-leirhehitorvlo  riT'  "^  P-^'"'^^  — -  exannnations  were 
The  results  ^^^^  ^^^^1'^  ^"'-  ^^'^^'^  ^''  ^'^^  ^""■-^^-'• 
recent,  in  which  the  a!nl^  i^^ta.- I  .rdl^H  T'  ^"^""'^''^^  '' 
and  larger  before  and  dn.-in.  .,.r!™„.  !'!/^''':^''^'l'>'/""»-«  "'""^'•""s 
were  others  in  which  tl 


small,  that 


sxampl 


es  w 


uung  the  paroxysms  than  in  the  inf.erval«-  thcro 
lie  number  during  the  chill  and  hot  sta 


ere  very  hard  to  find 


i?e  was  so 


taken  before  the  attack  and  durincr  each 


in  others  again,  slides 


stage  were  negative,  and  yet 


)     i 


I 


.'Sk 


1 


.m 


r 
» 

I''  i 

f'  1 

I' 

D 


,1 
J 


\H 


Hi 


Y:irt 


'\ii 


li 


i 


m 


56 


m 


i  K  :» 


wn 


subsequent  paroxysms  the  bodies  were  present  in  tlie  blood.  I  think,  on 
the  whole,  that  pigmented  bodies  in  the  red  corpuscles  'ire  more  numer- 
oiiM  bet'ore  and  duriiiu:  an  attack,  but  the  ditt'erence  is  liy  no  means  strik- 
ing, and  I  have  repeatedly  li;i'i  to  search  long  in  slides  j)n  pared  during 
a  paroxysm  for  a  single  example.  In  acute  cases  which  have  lasted 
some  weeks,  and  have  had  no  medicine,  the  amcvboid  bodies  have  seemed 
to  be  quite  as  abundant  at  one  nine  a?i  another.  Nor  ha\e  I  been  able 
to  see  any  special  diderenee  in  the  ibrm  of  the  bodies  just  before  or 
during  the  chill,  though  in  the  early  days  of  the  attack  they  may  be  snnill 
and  less  distinctly  pigmented,  or,  indeed,  may  present,  as  in  Case  XXIX.. 
already  referred  to,  the  appearance  of  vacuoles  containing  small  .solid 
bodies. 

The  renuirkable  segmentation  of  the  rosette  form  was  in  each  instance 
met  wilh  during  the  ])aroxysms,  and  Golgi  claims  to  have  traced  in  five 
cases  a  series  of  changes  corresponding  to  the  stages  of  the  attacks.  In 
the  intervals,  the  pigmented  bodies  gradually  increase  in  size  until  they 
fill  the  affected  red  corpuscles,  and,  finally,  the  pigment  collects  in  the 
centre,  as  shown  at  Fig.  9.  The  process  of  fission  coincides  with  the 
onset  and  course  of  the  paroxysm,  and  by  the  time  of  its  c<inclusion  the 
rosette  forms  disappear.  In  Case  LX. — a  (juartan  ague — an  attempt  was 
made  to  follow  these  changes,  with  the  following  result.  The  patient,  a 
lad  of  18,  had  had  malaria,  on  and  ofi",  for  a  year,  but  for  three  weeks 
before  admission  the  chills  had  been  recurring  with  regularity.  On 
Saturday,  the  (!th,  the  blood  was  examined  in  the  chill.  The  red  cor- 
puscles contained  many  large  pigmented  bodies,  and  the  rosette  forms 
were  numerous,  many  in  process  of  subdivision.  On  the  7th  and  8th, 
he  was  free  from  fever,  and  the  most  careful  examinations  of  the  blood 
failed  to  detect  any  forms  but  the  ordinary  pigmented  intracellular 
bodies.  They  did  not  seem  more  numerous  on  the  evening  of  the  'Stli 
than  they  were  on  the  7th.  On  the  9th,  hourly  examinations  of  the 
blood  were  made  between  11  a.  :\i.,  when  the  fever  began,  and  4  r.  ^r. 
In  the  first  two  slides,  there  were  very  many  pigmented  bodies  with  the 
granules  becoming  concentrated,  some  with  typical  rosettes  and  a  few  in 
course  of  segmentation.  In  the  specimens  taken  during  the  afternoon, 
the  process  of  division  was  readily  traced,  and  there  were  many  of  the 
small  bodies  in  the  field.  On  the  10th  the  note  is:  "  No  free  bodies,  all 
intracellular,  tolerably  numerous  ;  no  rosettes  ;  no  segmentation."  On 
the  11th,  several  examinations  were  made,  and  the  note  reads,  "abso- 
lutely none,  save  pigmented  forms  in  the  red."  On  the  12tli,  the  sllilc 
at  8  A.  M.  showed  large  numbers  of  pigmented  bodies,  some  with  the 
granules  irregularly  arranged,  other  with  distinct  I'osette.     Fever  began 


S7 

Certainly  the  soymentatioi!  seems  a«soei'.fo,1   ;,.  ..^ 

for  weeks  or  months.      Thus    in   CasoT  vl  .•       ?  ""'''  ^''''^'^ 

^---  -^i'  "hat  he eallecl dun  h' ZiuZ^LA!:u7T   "'  ""^""^^ 
tlH-ee  weeks  there  was  fever  with. na  d    ]  i  ' '"""'^  '  ^"^ 

some  occasions  to  10^      tL  n  '         '^'"Pniture  risi.,^.  on 

associated  with  IrLuJ^^^'T,  "^"  "'T''""'  ""''  ^^'^'-^  »"* 
and  hedi.l  not  look  anZi  "     Under  T""'^  ""'''''"  ""'^  ^'^^°''' 

-bsided,  but  tl>e  ores  Xwere'l    i    r-'''.V"/'"'^  '^''  '^'^^ 

of  the  first  observation  "  ^'""'  ""^  ''''^^  ^■-'"  ^'^  ^''^te 

Genuine  paroxsynis   may  occnr  in   tl„..«     i 

repeatedly  made  in  Case  YYV  ^'"-^'^'"8.      I  his  observation  was 

Jiiflnence  of  medicines  on  the  ornnnisim  ~C\u\..\,.r.  • 
tho  pigmented  bodies  to  disanpea7   L Hen  J  k-?""^'^  ^'""^^^ 

stu<lied  durino-  two  or  H,^     ^  ,    *^  ''"'"''  '^'^'^'^  ^^'c^-^'  "^"••^lly 

begun.  thi:':[;s;u.:;:;;::;x  T  f  f -""^^^"'-^  ^^- 

corpuscles  were  entirely  ;;r;.7''^'"''^'"f  ."^"^''"'"l-     In  a  few  days  the 

boie the >>CiT2:t;,  r^:  ^::::-^:— - 7^^^^ 

first  chill  „„  October  1st,  and  a  dailv  ::c:n::  ^l.^  hf  lOU  '  T  ' 
came  under  observation.  The  pigmented  1.!  i  t .' \h  '  ."  ! 
continued  so  on  the  11th  -md   I'/th   ,  »       /■  abunaant,  and 

paroxysm  to  lO-,-      n       •  '      ''"  ^^'^  temperature  rose  in  the 


f"i 


ij 


5 


It  I 


!•  « 


! 


r>H 


■ 


'   • 


i' 


vm '  '  i 


i  I 


The  bodies  were  proHont  on  the  l.'Uh,  ami  ii  ftnv  on  thu  14tli.  Tl»cy  were 
nut  (nimd  on  siil)S((|ii(>nt  (lavH.  In  less  acute  ca«'H  the  iiction  of  the 
(jiiinine  did  not,  .seem  to  be  so  prnnipt,  and  the  creweents  did  not  <lisu|)poar 
80  rapidly  innU'r  its  use.  CiTtainly,  in  reeent  eases  this  luedieini!  aets  as 
a  positive  specifics  a;,'ainst  these  or<^anisni.s,  just  as  it  does  aj^ainst  tiio 
niahidy  itself.  ^Vrsenic  does  not  appear  to  intliienco  the  pii^mented  inlra- 
celhdar  Ijodies.  In  a  ehronie  case,  witiiout  chills,  but  with  irreirular 
fever,  the  crescents  ])ersiste(l  for"  over  five  week-  alrhoui,di  the  patient 
had  improved  in  jreneral  hwilth  and  vij^or,  and  was  no  longer  anainiic. 
'1  hallin  and  antifebrin  were  given  in  some  cases  without  any  noticeable 
results.  As  is  well  known  to  practitioners  in  malarial  regions,  there  arc 
cases  of  internuttent  fever  which  subside  without  special  treatment.  I 
have  had  several  j)atients  in  whom,  without  any  (luinine,  tln^  chills 
stopped  or  recurred  very  irregularly.  In  Case  LXVI.,  the  crescents 
aopeared  in  the  blood,  which  at  first  contained  only  the  intracellular 
forms. 

Cases  examined  with  negative  result, — As  before  stated,  there  were  eight 
instances  of  apparently  true  malaria  in  which  the  organisms  were  not 
found,  and  'o  these  I  shall  now  briefly  refer.  1  would  remark,  in  the 
first  place,  that  wo  cannot  always  rely  upon  one,  or  even  two,  csxamina- 
tions  of  the  blood  for  these  bodies.  They  may  be  very  scanty,  or  thev 
may  be  present  at  one  examination  and  absent  at  the  next.  For  ex- 
ample, Case  XLI.,  a  man,  let.  20,  was  admitted  with  a  temperature 
of  104^.  He  had  been  cranberry-])icking  in  New  Jersey,  and  had 
been  ill  for  a  week  with  fever  and  '  u  .'nite  pains,  but  no  chills.  He 
was  so  very  dull,  that  as  the  feve  p  rsistcd,  typhoid  was  suspected, 
although,  as  a  cranberry-picker,  maiaria  was  first  thought  of  The 
blood  was  examined  on  three  occasions  with  negative  results,  but  on  tla; 
fourth  observation,  five  days  after  admission,  and  when  the  temperature 
ha<l  fallen  to  normal,  crescents  were  found,  which  continued  in  the  blood 
until  he  was  thoroughly  cinchonized.     The  cases  are  as  follows: 

Cask  X. — Child,  ict.  5;  chills  and  fever  in  Maryland  nine  months 
ago,  occasional  chills  since,  the  last  two  weeks  ago;  spleen  four  inches 
vertical  diameter;  had  taken  quinine,  none  recently.  One  examina- 
tion. 

Case  XI. — Man,  i^t.  19;  never  malaria  before.  Four  distinct  par- 
oxysms. Slides  examined  from  fifth  and  sixth,  taken  in  cold,  hot,  and 
sweating  stages.     No  quinine.     I  did  not  see  the  case  subsequently. 

Ca-f.  XX.— Man,  .o't.  40.  First  attack  six  mouths  ago.  Chill  on 
and  off  for  past  three  months.  Blood  examined  three  days  after  lust 
chill.     Had  taken  quinine  for  two  days.     Spleen  enlarged. 


/>9 

cxaMiinatiuas.  without  rosu  ^.  ""^  K'^en.     Ihrco  8n)«<.,,„cnt 

Cahh  XXVIII.-.Aran,  tvt.   iX.      ,.„.nitto,l  ..,,   J4tl,.     Woll-marl-,.,] 
•■I'.llH  for  c.,,l,t  weeks  ;  l.u.l  on.  ,,1,,..  ho  c-anu.  in,  and  four  at,  1 

examine,!  on   28th   two  sII.L.m      r(      i     i   i       '"•'"' ^'^"'^  ""i'''-    -"'"od 
«inee  adn.is.ion.  "   '""'   ''"''  ''^'"""'^  *?'••  "^^  --''  ^-Y 

Cask  LI  [.-Man,  jot.  25.     Chilis  .nd  fever  for  six  day.s      Hlood  ox 
a-n-ned  .n  eh.ll,  and  on  the  ioilowin,  day.     Had  had  ,uinh,e 

CO  Intel  out.     In  (  ase  X.,  the  ch.ld  was  i„.o,.^d.t  from  tl.e  countrv  "and 
only  one  exam.natio,.  wa,s  ,nade.     Case  XI.  Jas  u,.doub  e  Za  case  of 

t''^  '"!'  and  s.xth  paroxysn,  was  „,.,,uive.  I  did  not  see  the  ,  tlent 
am  'n,..her  exan.inations  were  not  ,na,le.  In  , -„se  XXXVI  tt' 
l'o.lie.  we,-e  not  found  on  two  oeeasions  Thi.  ,.  ^^^^-^\i/^-  the 
followed  and  f  ,ln  .,  M  ,      '",'-"•■"""■•      ^'"^  '"an  also  could  not  be 

loumNc,!,  and  J.  do  not  know  Im  suhse.iuent  hist.u'v. 

wiA ','Z;!  ""■  "'■'?.';"'""-'-I' '"  «■'■.>■  "-iilcnt  that  we  are  ,leali„.  here 


iind  with  bodies  wiiich  1 


lav 


niii 


cocci,  and  bacteria  of  certain  acute  d 


e  no  relation  whatever  to  tl 


tion  to  the  remarkabL 

by  Luveran,  Kichaid,  iMarehiaf 


ise 


e  iinan 


'.e  spiriil.'i 
uses.     I  would  call  atten- 


iniity  in  the  description  of  these  i)a,-asites 
■  iva  and  Celli,  Councilnum,  Gol«i,  and 


1 

I. 


i   m 


1 

1 

':•  ' 

•J 

■;.9 

'•  ;■      i 

60 


,1  ; » 


;i  ■- 


f 


myself.  Lavcran's  oriifinal  (lcscriptii)n  is  well-nigh  coinjilote,  and  sub- 
seiiiient  workers  have  done  little  else  than  conlirni  his  results,  though  to 
Marehiaf'ava  and  Celli  is  due  the  credit  of  insisting  upon  the  aniceboid 
character  of  the  intracellular  form.  Before  discussing  the  relation  of 
the  forms  to  each  other,  it  will  be  necessary  to  take  a  brief  review  of 
cognate  organisms  occurring  in  the  blood,  upon  which  recent  investiga- 
tions throw  an  im])ortant  light. 

It  has  been  known  for  some  years  that  hrematozoa  exist  in  the  frog; 
one  form,  a  flagellate  organism,  the  Trypanosoma  sanguinis,  described 
by  Gruby  in  1841),  is  a  well-recognized  monad  ;  a  second,  the  Drepaiii- 
dium  ranarum,  of  Lankester,  is  evidently  a  gregarine,  possibly  a  larval 
form,  as  he  suggests.'  Having  been  long  familiar  with  these  bodies,'^ 
which  were  very  abundant  during  several  winters  in  the  frogs  in  luy 
laboratory  at  Montreal,  I  was  at  once  struck  with  an  apparent  similarity 
to  them  of  the  forms  found  in  malarial  blood.  The  crescent-shaped 
body  in  particular  resembles  strongly  certain  of  the  gregarines,  and  I 
thought  it  possible  that  we  had  here  an  instance  of  a  sporozoon  becoming 
flagellate  at  one  stage  of  its  development  as  Rivolta  affirms  may  be  the 
case.  I  soon  discovered,  however,  that  there  were  other  observations 
on  hiematoza  which  bore  more  directly  on  the  subject,  and  rendered 
possible  a  more  likely  explanation.  Mitrophanow,'  in  18815,  announced 
the  discovery,  in  the  blood  of  the  carp  and  of  the  mud-fish,  of  parasites 
belonging  to  the  flagellate  infusoria.  A  description  of  these  forms  need 
not  detain  us,  further  than  to  note  that  they  were  polymorphic,  and  one 
stage  was  represented  by  an  amoeboid  body  without  Hagella. 

In  a  report  published  by  the  Punjab  Government,  December  3,  1880, 
and  in  the  VetcriiKir;/  Journal,  London,  1881-82,  my  friend,  Dr.  Griffilh 
Evans,  described  a  )iew  and  very  fatal  disease  known  as  t^urm,  which 
prevailed  among  horses,  mules,  and  camels  in  India,  and  in  which  he 
discovered  a  /arasite  in  the  blood  during  life.  At  first  Evans  believed 
it  to  be  a  spirillum,  but  subseciuently  came  to  theconclusiim  that  itwasa 
much  Ligher  organism.  His  observations  have  an  important  bearing  on 
the  question  of  the  parasites  in  malaria.  In  1885,  Veterinary-Surgeon 
Steel  published  "An  Investigation  into  an  Obscure  and  Fatal  Disease 
among  Transport  Mules  in  British  Burimi,"  which  also  proved  to  be 
surra.  A  careful  clinical  investigation  of  the  disease  led  to  the  conchi- 
eion  that  it  wa^  a  true  relapsing  fever,  very  similar  to  recurrent  lever  of 
man.     Steel  found  the  parasite  described  by  Evans  in  all  cases,  and  ile- 

'  yimrtcrly  .Journiil  of  INIicroscopicnl  Scionco,  vol.  xxii. 

'•i  CiuuKlian  Niit\iialist,  tS8:). 

»  Hiolog:     has  Centnilbliitt,  lid,  iii.  p.  115 


61 

the  rosnlf«  of  1  •    •         "^      ''"''""^'  '"   ^'^^  P'>Per  just  mentioned,  mves 

In   the   Ji^oloffisches    Centmlbhdt,    LS.So,    Proiessor   Danielowskv    of 

Charkof.n,akes  an  important  contribution  to  the  subject      He  L^^^^ 

h  t  1  ypanoson,a   the  welM  noun  flagellate  organisnAf  fro't^  b  o  d 

to  ..-,t,..th  greater  confidence,  that  we  are  here  dealing  nith  the 


f     I 
it      ■■ 


Journal  of  (lu-  Uoyal  >I 


oyii 
yiiiuterly  Juurijul  of  M 


H'I'lW.lllicill  ,S,)cicl}-,  ISSli. 


'  Centiiilbliitt  r.  il 


ll'IO.-iL'0|liCill  Sci 


L'lico,  is7a. 


iu  lIlLMlicillHilK'll   W 


33fiiscliartt.li,  Nos.  4!  and  X:,  ]S8P. 


?:  % 


r 

s 
I 

l 

D 


'i      I 


;! 


62 


varieties  of  a  ln<!;hly  polymorphic  species,  and  not  with  two  or  three 
different  organisms.  The  flagelhite  form  is  doubtless  the  adult  condi- 
tion ;  and  it  is  interesting  to  note,  in  contrast  to  the  luematozoa  of  tJie 
rat  and  of  the  Hum'.  disease,  the  comparative  infrequency  of  its  occur- 
rence. Laveran  met  with  it  ninety-two  times  in  four  hundred  and 
thirty-two  eases,  ar,d  (.'ouncilnian  eleven  times  in  eighty  cases.  The 
steps  in  development  remain  to  be  worked  out.  It  seems  clear,  how- 
ever, that  the  pigmented  amceboid  form  may  become  transformed  into  a 
sporocyst  (represented  by  the  rosette  form  and  its  changes),  or  into  an 
encysted  body  (resting  form  i,  the  crescent.  The  gaps  in  our  knowledge 
relate  specially  to  ihe  form  and  manner  of  entrance  of  the  parasite  into 
the  red  cori)Uscle.  Do  the  solid  particles  contained  in  the  vacuoles 
(Figs.  5  and  6)  represent  the  earliest  stage?  I  think  it  highly  probable 
tiuit  they  do,  and  that  they,  with  the  hyaline  unpigmented  bodies,  are 
the  immature  forms.  The  s[)ore-like  structures  which  result  from  the 
segmentation  of  the  rosette  form  do  not  resemble  the  small  solid  bodies 
seen  in  the  red  corpuscles,  but  are  rather  like  the  tin}'  free  pigmented 
forms  which,  in  some  cases,  were  abundant  in  the  plasma.  Of  the  latter, 
various  sizes  are  found,  and  it  is  possible  that  from  them  the  adult 
flagellate  bodies  arise.  Golgi  suggests  that  the  spores,  resulting  from  tlii! 
segmentation  pass  to  the  spleen,  and  there  attack  the  red  corpuscles,  in 
which  they  develop  into  amadioid  forms.  As  at  present  the  data  are 
not  available  for  a  final  decision,  a  further  consideration  of  these  points 
need  not  detain  us.  There  is  sufficient  evidence  to  show  tiiatthe  various 
forms  are  only  phases  in  tlic  life-history  of  one,  the  flagellate  i)roto/.oa, 
belonging  to  the  order  Flagellata-Pantostomata.  ]Mitrophanow  suggests 
a  new  gemis,  ILematomonas,  to  include  the  monad  luematozoa  ;  ])ut 
Crookshank,  who  has  curefuUy  worked  out  the  afhnities  of  the  parasites 
of  the  rat,  the  fish,  and  the  snrrn  disease,  has  referred  them  to  the  genus 
Tv'chomonas.  The  organism  here  described  has  not,  however,  the 
characteristic  marks  oi'  a  Trichomonas ;  for  it  lacks  the  undulatiiii,' 
fringe  on  one  side,  and  the  caudal  filament.  Nor  d'K'S  it  agree  with  the 
features  of  a  Cercomonas ;  so  that,  meanwhile,  until  the  true  affinities 
are  determined  by  an  expert,  its  [)roper  place  seems  to  be  the  genus 
IIiomatomcuKis  of  Mitrophanow,  which  conveniently  inchules  all  monuik 
parasitic  in  the  blood.  Thus:  geiuis,  Ihcmatomonas  ;  species,  Ihemato- 
nionas  raalarite.  Definition  :  IJody  })lastic,  ovoid,  or  globose,  no  differ- 
entiation of  protoplasm,  which  contains  pigment  grains;  flagella  vari- 
able, from  one  to  four.  Highly  polymorphic,  occurring  in  (1)  iima'hnid 
form;  (2)  crescents,  encysted  form;  (3)  sporocysts  ;  (4)  circular,  free, 
pigmented  bodies.     The  name  designates  the  natural  affinities  of  the 


68 

parasite,  the  l.abitat,  and  the  conditions  under  wliich  ;,  . 

grounds  ,t  seems  preferable  to  that  of  PI  occurs,  on  which 

by  Marciu-afavu  and  Celh-.  Pl"«"^"'lunu  niah.rias  .suggested 

lie/atiou  of  the  pamsifc.^  h  fhn  .U.ra,^      Tl 
l^ere  as  in  so  nuuiv  affections  in  w   i  '  ''"""'  '^'^'''^'^  '''''''  "« 

Are  they  pathog^^ic,  or  I3    ]    '  tor  T'"''"'""  '''''  ^^^"  ^«"-l  ^ 
^vbieli  in  some  n.iv  f.  rnislt '  •  ^  ^  "^-^ocuited  with   the  disease 

evidence  of  th^  .  Z^:  ':!:^^'  ^^"''^  ''  '''''  "-^^"^  ^  ^ 
constancy  of  their  p,-esen,:n":;'"  ^r''  "^^'  ^"^™'  "- 
nal  regions,  the  dLtructi^;  m^n^  L:;  r;:'^'^''^"'^^^  ^  "-^- 
their  abundance  in  ti.  g-aver  fb^ro^  L^^r7"^^^^%-" 
considerations,  wei-dity  as  fl.Pv  ,„  c"&ease.     But  even  these 

to  all,  in  the  absJ^ce  Jc^^  i      LirP  ''"'''  "^^  ^^"^  ---^-» 
afforded  in  the  case  of  cert^rn    ]  ^''T"'""'''''  ^"^'^  "^  «'»   ^^^ 

i-late  aiu,  gro.  these  1^^  ^  <,    f  ^^5  '7"^^"-     ^"^'"^^^^  ^« 
chiafava  and  Celli  have  shown  tint  the  ,   '^  ^'  '"''"  ^"'^^^'-     ^^^''^^- 

with  bloo<,  taken  f.-om  a  oas  f  '^l^  irSrV'  '"^^'^  ^^^^^""« 
by  genuine  ague  paroxysms,  in  whicirthe    ,1  '    •"  '  "''''''^'  ^""« 

bat  in  regions  where  malria  s  ev  lent  1  ,"  "^  the  parasites  ; 
-bolly  free  fron,  objections.  A  .e  c's  ;?  7  ^-^I-'-^^^nts  are  not 
doubted  cases  of  malaria  would  l^^  .^^  1  t"^''""  T  "^■ 
on  the  three  cases  in  which  I  did  nnr  fi,    ^^^'  '^  ""  '^"''''"^^  stress 

were  not  followed  from  day  to  d  v  w  M     I  ^'"'''^''''  ''  '^''  ^''''''''' 

any  value  to  the  observatiiif  1  2:^  '^  i!"^" -"^  '"T"^'  *^  ^^- 
tozoa  are  not  uncommon  in  anunaV  .  <  t  if  "'  '"l"'^  '^''^*  ^'•^'"^■ 
interfere  seriously  with  the  health  of'thei;  ho  t  riS  T  "^^''''''  ^^ 
•stances,  the  association  of  a  snecifin  f  ,  ^  "''""  ^''^^^*^  ^ircum- 

-i.aal  makes  it  all  the  J:  ^^^^^^^^  in  an 

A  further  study  of  the  sarm  di  e.^e   1,  t  ?"'"',  "  I^'-^^'^«fc-»'«. 

tl>e  new  light  which  Evans  and  C^^.  L^kn     ^  *"  '^  '""'^^  ^^'^ 
conditions  under  which  the  disease  2  .     '     "'"""  "I''^"  ^^-     The 

^.aracter,  are  so  similar  ^t^ J::^  •rt:^^^  '^  'n'""^ 
lis  patliogfiiy  woiilil  have  a  vcji-v  ,!;,.„„,  I       •  oxplanation  of 

"™™'"".'  "'.-'■-  - gicai  as j:  r  , ' ; :,  r'"'rv't"'  ^«- 

tive  anatomical  chan.r,.y  u-hich  p..,,  1  ,.'"'" /"'^''""•-  i^  irst,  the  posi- 
changes  ^.^n  .,i^.  ^  :!'tZ  ^:^^::fy^^  to  their  acLn. 
'I'sease  de{)ends.    T  refer  to  the  ,]o-u.,  V      \  '^  «ym|,toms  of  the 

^vHich  can  be  fbllowcd'.ti  tt^^  "V  '"  ■"'  •'''-'^-'^--Ics, 
''""  "^'  tissue  brought  al  o      t    T'  ""^  '^  "^  "•^^"  ''''""-'  -'  altera: 

^-''e  second  fact  is  ti.e  ^t::;  0  ^^i,  r:!;;:^ "^  "^"  .^^•^'•^^'  -  ^-- 

'"-  "pon  the  parasites.     The  simul- 


'    1 


( 


r 
i 

:^m  i-'    I 


I   ri 


I  1 


.1 


64 


•  aneoiis  disappearance  of  the  symptoms  of  the  disease  and  the  hrema- 
tozoa  suggests  that  the  specilic  influence  of  the  medicine  is  ujion  the 
parasites,  though  it  may  l)e  urged  tliut  tlie  quinine,  wliile  curing  the 
disease,  simply  removes  the  conditions  which  ])ermit  of  the!  •  growth  in 
the  blood. 

Practical  considcraiiom^. — An  interesting  practical  point  is  the  diag- 
nostic value  of  the  presence  of  these  bodies.  There  were  six  or  eight 
cases  in  which  the  examination  of  the  blood  proved  of  great  service  in 
determining  the  existence  of  malaria.  Some  of  these  are  worth  men- 
tioning. One  of  the  first  was  a  man  ret.  37,  who  had  been  under  obser- 
vation on  three  or  four  occasions  with  antemia  and  an  enlarged  spleen. 
He  had  had  three  attacks  of  huematemesis.  There  was  no  history  of 
malaria,  and,  from  the  gravity  of  the  case,  I  was  led  to  regard  it  as  one 
of  severe  splenic  anaemia.  On  his  fourth  visit,  however,  a  careful  ex- 
amination of  the  blood  revealed  the  presence  of  the  parasites,  and  I 
gave,  in  consequence,  a  more  fiivorable  prognosis  in  the  case,  which  has 
since  been  justified.  In  an  instance  of  pernicics  malaria  admitted  to 
the  Philadelphia  Hospital,  under  the  care  of  m  volleague,  Dr.  J.  H. 
Musser,  the  diagnosis  rested  on  the  discovery  in  .-iie  blood  of  the  char- 
acteristic changes  in  the  corpuscles.  To  a  third  case,  XL.,  I  have 
already  referred,  and  there  were  four  or  five  other  instances  of  chronic 
malaria  in  which  the  nature  of  the  disease  was  deternuned  by  an  ex- 
amination of  the  blood.  On  the  other  hand,  in  many  cases  of  suspected 
malaria,  the  absence  of  these  bodies  led  to  a  more  careful  examination, 
and  to  the  discovery  of  the  cause  of  tlie  chills  and  fever.  Four  of  tluse 
were  cases  of  phthisis  with  ill-defined  physical  signs;  in  a  fifth,  after 
several  negative  blood-examinations,  the  ague-like  paroxysms  Avcrc 
found  to  be  due  to  a  septic  pneumonia;  in  a  sixth  and  seventh,  renal 
disease  was  discovered.  I  feel  confident  tinit,  in  malarial  regions,  the 
examination  of  the  blood  will  j)rove,  in  skilled  hands,  a  most  valuable 
aid  in  the  diagnosis  of  many  obscure  cases. 

Melanamla.- — These  researches  on  nialai'ia  throv  ji  i  ^n  the  forma 
tion  of  pigment  in  the  blood  and  various  organs  iii  i'  o  ..aronie  cases. 
Evidently  the  primary  change  is  in  the  red  blooci  corpuscle,  which  is 
gradually  destroyed  by  the  amoeboid  form  of  the  parasite.  ICvery  stage 
of  this  ])rocess  can  ha  readily  trjiccd,  and  these  observations  bear  out 
the  more  recent  views  on  the  origin  of  the  jiigment  in  the  blood  itself. 
The  pigmentary  degeneration  of  the  red  cor[)uscles  noticed  long  ago  by 
Frerichs  and  Kelsch,'  was  no  doubt  the  same  as  here  described.    The 


A  colorless  c 


'  ArcUiv  (1.  riijsiologie,  187S. 


65 


of  the  spleen  „„d  bone-m-.,Tf,„.  „   ■  "'"■'''  """  ''^  ">"  »"» 

...vo  ,h'o  offe,e  ^"0,^  ,1  •:'',:::,■  ^-'li'' -  :■■  "=»'■'■.- 

com,,,,,,,  on„„gh  when  S,e,v„,,W,„,    .     ""h     teluT"""'"  •'","'"'"'■ 
now  become  very  rare  i„   Pl.il,  1  .   ,  .  °"',"'',  "c'Winoivn  arliclc,  has 

n.,.!  Cell!  h,.ve  «.„,,,       e!  ,  '^f  /"  """  «"*''  '^I"-'-'"'™ 

mat,.ix.     0„„„ei„„„T,  l,?,.  Abb!  ^  ,       ttZi' u"      "''  '','  "  ''™"™ 

accompan,.i„,.she.eh  >vas  t„k         !„,''%;""■"""'  '"""  " '''*  "- 

u  i„.  io).     It  represents  a  small  brain- 

Fio.  15. 


".itMiu,  a„a  m  (,ve  (hurt,  aro  pigmentea  bodies. 

capillary  filled  with  corpuscles,  in  manv  of  w],;  i 

^vhich  stain  deeply  and  so  f.r  ■'  7  ''""'  '"^"'^"ted  bodies 

..'n,.me,...-„,r.i::r-^=:trt;i::!;i^ 


'  American  Journal  of  tl.o  Modical  Scioncos,  1851. 

5 


"  Ibid.,  1885. 


1 

;i 

;• 

'1     Mrl' 

i 

i  ■ 

-.'■J'J 


I 


m 


III  1 


! .  t! '  *  ii 


'  ■  i:; 


66 

Only  one  instance  of  futal  malaria  came  under  observation,  a  man  set. 
70,  iulmittod  to  Dr.  Mu.v^cr's  wards  on  October  2"itli.  He  bad  been  on 
tbe  Istbnuis  of  Panama  aii<l  in  Gcor;;ii!  ,ind  bad  cbills  and  fever  in  botb 
places;  last  cbill  was  tliree  days  bel'oro  admission.  He  had  also  luul 
ha;maturia.  He  was  very  anremic,  tbe  spleen  was  sligbtly  enlarged,  tbe 
temperature  101. :'>^.  Tbere  was  jjroat  stiipoi,  and  be  wu.h  ruujed  v.ith 
difbcullv  ;  tbe  tniigue  was  dry.  Tiie  tcmijeratun,  ')ecam\'  ^.tibnormal  on 
Ocla^jcv  27tb  ami  28tb.  lv\;!.minati(m  of  tbe  blood  showed  many  pig- 
mented iKHJii.-  in  tbo  reel  corpuscles,  numerous  free  circular  forms,  a  few 
crescents,  and  <i:ver!d  flagellate  organi.-^ms.  Tbe  stupor  deepened  to 
coma,  and  h(  died  nu  tbo  nigbt  of  October  28tb.  Tbe  spleen  and  liver 
sbowed  typical  pigmentation,  and  tbe  bone-marnnv  was  also  very  dark. 
The  Bpleeu-pulp  contained  free  pigment  and  many  large  cells,  some  of 
wbicb  wore  illled  witli  dark  granules,  wbile  in  otb>  rs  tbere  were  bodies 
identical  with  tbe  small  pigmented  forms  so  abrsidant  in  tbe  blood 
during  life.  Tbe  marrow  presented  similar  cbang(  ?.  Tbe  number  of 
red  corpuscles  containing  the  pigmented  bodies  was  not  great,  nor  were 
tbe  capillaries  of  the  liver  or  tbe  brain  stuffed  with  them,  as  in  tbe  in- 
stances of  pernicious  malaria  just  referred  to.  Pr(>bably  this  was  an 
instance  of  severe  malarial  cachexia  of  many  months'  duration,  and 
scarcely  should  be  grouped  with  the  pernicious  comatose  form. 

To  my  colleagues,  Drs.  Curtin,  Neff",  and  ]\Iusser,  I  am  indebted  for 
tbe  privilege  of  examining  the  malarial  cases  in  their  wards;  and  to  my 
resident  ])]iysicians,  Drs.  Donobue,  Albertson,  and  Westcott,  for  assist- 
ance wbicb  materially  lightened  my  work.  Ocioher  28,  1886. 


Timid  c<'lii)i<)roccnf<. 


This  rare  i)arasite  was  reared  experimentally  by  feeding  a  dog  with 
hydatids  from  the  liver  of  a  pig.  The  animal  wii  I'illed  about  seven 
weeks  after  the  feeding  nvben  tbe  intestine  was  fo'  <  'o  contain  many 
hundreds  of  tl">  mature  ta])ewornis.  Tiie  porti  •  ot  bowel  exiiibited 
bad  many  adi':'.. 'it  to  tbe  mucous  mcmbraii  ;  •  nn  tbe  small  si/e  of 

the  worms,  only  n  few  lines  in  length,  the  <-\.  apt  to  bo  overlooked. 
Cobboid  states  that  the  only  specimens  procuc'>  i  'a  England  have  been 
experimentally  reared.  Dr.  Leidy  has  never  iiitr  ihc  adult  worm  in  tliis 
eountrv.  That  it  may  occur  here  in  the  dog  is  ^  r^-  .^vich^it  i'rom  tiie 
frequency  with  wbicb  echinococcus  cysts  (tbe  lar  ; -o  met  with  in  the 
hog  and  other  animals.  ^September  24,  1885. 


^,  ! 


07 
Ci,Meercus  cclluloscB  of  hndn,  heart,  and  voluntary  muscles. 
The  "measlo-'  or  cysticercus  of  the  T.ouia  solium  is  found  very  fre 
tra  0  the  extraonl.na.-y  nu.nbe,.  which  n.av  exist  in  a  well  .^.-i  1    d 

ioity    il  encysted,  and   very  readily  seen  as  o,.a.j,.e  white  bodies  th« 
s...eof  hn-ge  peas.     It  is  rcnarkable  that  the  a,,  .nal  dies  no     cv  n 

In  the  heart  the  cysts  are  also  ve.y  nu.nc.-ous  and  at  least  a  dozen 
may  be  counted  beneath  the  endocardiu.n  of  the  left  venS  "l^ 
were_  very  generally  distributed  throughout  the  vol  ^t  ^  ,  ^tles  a^d 
"Jtl..scase  the  <l.agnosis  of  the  condition  could  be  .na.[e  w  1  Uf  a 
d  t^;)  '^'^^"^'"f  ,7-  the  ,nost  careful  examination  m  y  fi  to 
detect  thenyvnd  probably  the  chief  danger  is  in  these  cases,  as  of  conrse 
a^sjngle  cysticercus  taken  in  a  slice  of  raw  '<  schinken  "  or  in  ''  .^^''l 

In  this  ease  parasites  were  so  numerous  that  I  made  a  careful  inspec- 
onof  themouh  to  see  .f  their  presence  could  not  be  determin  d  Tn 
he  hngua  and  buccal  muscles.  Beneath  the  tongue  three  or  foe  , Id 
hd,s^,nctly  seen,  and  the  affection  .night  really^  have  been  di  n  ed 
dunng  1  fe  in  th.s  way.  As  with  the  trichina,  the  ho<.  appears  to  harbor 
the  cysfcerc.  with  very  little  inconvenience  and  tl^e  syn  .  ,.  !f ^"  ' 
affect..!  are  very  n.definite.  In  this  country  pork  "meLle"'  t^ 
nea  Iv  so  frequent  as  the  veal  and  beef  form-tV.  larva  of  the  T 
mediocanellata.  „        •»  va  oi   nie  i. 

/September  24, 1885. 


Liver,  with  dilatation  and  calcification  of  the  bile-duct.,  the  effect  of  flukes. 

The  liver  fluke,  Distoma  hepaticum,  so  com.non  in  Europe    is  not 

very  often  .net  with  in  sheep  and  cattle  in  this  country    u'  i     Z 

xper,e..ce  .t  .s  rare  to  fi.ul  he.-e  the  advanced  changes  do  id    a 

of  each  week  at  the  abattoir,  which,  owing  to  the  elaborate  sv.to,n    P 
-pecfon,  both  ante-  and  postmortem,  offers  one  of  t  e  b^t  s    f 

i^urope  for  the  study  of  compa.-ative  pathology  and  heln.intholo^  and 


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68 

through  the  kindness  of  Dr.  ITcrtwig  I  was  enabled  to  secure  a  hirgo 
nuinluT  of  interesting  specimens. 

Tlie  liver  liere  shown  represents  a  condition  which  may  be  seen  almost 
any  day.  Tiic  organ  was  not  nuicii  enlarged  and  externally  did  not 
look  much  altered,  though  here  and  there  a  gray-white  spot  could  be 
seen.  I  have  dissected  the  bile-ducts  of  the  rigiit  lobe  from  the  under 
surface,  leaving  intact  the  upper  portion  of  the  liver  substance.  The 
ai)pearanec  is  not  a  little  remarkable.  The  ducts  arc  uniformly  enlarged 
and  converted  into  rigid,  calcified  tubes.  The  primary  branches  arc  as 
thick  as  the  thumb  and  the  teruiinal  ones  toward  the  edge  of  the  liver 
the  size  of  pipe-stems.  AV^hen  broken  the  wall  is  from  one  to  two  lints 
in  thickness,  cal(;ified,  quite  brittle,  and  without  a  trace  of  any  tissue. 
Here  and  there  are  saccular  dilatations.  The  inner  surface  is  roughened 
and  irregular,  stained  of  a  black  or  yellow-brown  color,  and  in  the  larger 
tub^s  there  were  a  few  tlukes.  In  other  specimens  I  have  found  them 
in  numbers,  dead,  broken  up,  and  calcified.  A  bile-stained  glairy  mucus 
filled  the  tubes.  The  condition  is  one  of  chronic  cholangitis  due  to  the 
irritation  of  the  fiukes.  It  is  interesting  to  note  that  the  liver  sub- 
stance is  not  much  changed,  and  is  not  to  any  extent  cirrhotic.  The 
aninnil  from  which  this  specimen  came  was  fairly  well  nourished,  sutH- 
ciently  so  to  escape  the  vigilant  inspectors.  In  shec[)  <he  changes  in 
the  liver  may  be  much  more  advanced  and  the  symptoms  of  the  aifcc- 
tion,  known  pojiularly  as  the  '"  rot,"  closely  resemble  those  of  cirrhosis 
of  the  liver  in  man.  September  24,  1885. 


Hydatids  passed  with  the  urine. 

The  i)atient,  George  S.,  let.  58  years,  an  Englishman,  resident  of 
Ontario  for  thirty -five  years,  at  present  a  I'armer,  but  formerly  a  butcher 
for  fifteen  years.  Always  enjoyed  good  health  until  about  four  years 
ago,  when  he  had  a  severe  attack  of  ne[)hritic  colic  on  tlie  right  side, 
lasting  only  a  short  time  and  quickly  relieved.  Had  no  further  trouble 
until  two  years  afterward,  when  a  similar  attack  occurred,  confining 
him  to  bed  fijr  several  weeks  ;  some  days  he  was  better,  but  always 
worse  on  exertion.  After  a  period  of  improvement  for  several  weeks, 
during  which  time  he  was  able  to  attend  to  his  farm  duties,  he  felt  pain 
and  uneasiness  over  the  right  kidney,  followed  in  a  day  or  two  by  pain 
at  the  point  of  the  penis,  which  continued  for  several  hours,  and  was 
relieved  by  the  passage  of  gelatinous-looking  masses  in  the  urine.  These 
bodies — hydatid  —he  has  continued  to  pass  at  intervals  of  from  two  to 


60 

tions  at  the  penis  No  tuZ.t  "' ,  '^'"'^r  "'"'  !""»  °r  nncasy  sensa- 
n^^^^o^.ooI7;kX^y  Wl^^r''"''  •'""  discovered  in  tl.o 
!-•"  an<l  distress  in  nin... v  '  ''"'''""  '^  '^''''  ""'''^^^  ^^ 

Lydatids,  he  enjoys  gd  Z  /  XT  T'  "  •'?  ''"''"-^^  «^'  ^^'° 
lH.u-els  regular.  '  ^"''  "^' ^^■^"y''t ;  "Pl^otitc  goud  ; 

Tlie  speoinu-ns,   uliieh   were  given  to  mo   fn,.  ,>.       •     .•       , 
Palmer  Ifow.)rrl  ,.fAr     ,      ,       ^.  **"   ^-^'""mation  by  Dr. 

aimci  llo\  aid,  of  Montreal,  consisted  of  ten  or  a  dozen  I.v<]..f,V1        / 
ranging   n  s  ze  from  n  no.,  t,.  „  .  li}(latid  cvsts, 

'■^^^'^-  n./z::j-:XtZ;:;:^::::^t;:;: ""■»■;'■? 

was  in  communication  ^yUh  flf       •        '=  ^^^  ^^  ^^'^  "*  ^^  J'»y^'»-  oue  which 

'• ».  .^ ic:.":r\t:  3^^^^     otr  .<";.'■«  ^'^ 

di'op  of; the  uruie  in  whioT,  tl.o,  '      -*■  examination  of  a 

:K-.'*tL  hook,:: ::;;';':  :„:•  ™"-  - "°"» '"■""'■*  ■■"-> "-  c,,... 

>*  eicn  (spleen),  i/ecjjcai?  iV^ms,  1884. 

«7^«^e  25,  1885. 


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tlio  <rastri( 
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solution  of 

Samuel  '. 
Ho.spitiil  01 
<'<iiii|)liiiii   ( 

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eonipdled 
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tendency  to 
tlu!  autumn 
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seem  to'liav 
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l)y  two  sup  J) 

lie  WilS   o 

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fast — and  ea 


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/-XX 


Kxtrnptod  from  the 
Amon-Mn  J,.,.rnMl  of  tho  Modical  Science,  for  April,  1880. 


ATIlOniY  OF  THE  STO.MACJl, 

WITH  THE 

CLINICAL  FKATURKS  OF  IMKKSSIVK  PKRNICIOUS  AN.IvMIA. 


I'HorKHMUH 


M  TO 


By  Viu-.imuvK  P.  Uf.shy,  JF  D 

«*■  .uN.c.u.  MKn.a.sK  ,^■  tuk  .m„>,,„ki,,.„,.  .....vcmnic,  ,.„v.„r,A 

TiIKr.|..H..„KU.a0H,.,TA..,   ,.HM.A..KL,.„M. 

ANM) 
WlLMAM  (>sij;u,   .M.D., 


"I  l'ull,„l„xi.-l»  ,ig,c«  will,  ll„.  ,i„to«„„t  „!■  W..|,.,    i    '  !„?''°    7 

r  i,v:;r  :;■  "'■",""•' '"'"'  '■'■  ^^•"-^■^^^:^^^ 

•'""'■laia  "f  wJik  ,i.    l„i  ,,1^   , '.,  "''^'    '-lore  tl,i,  dal«  l,„  llegHuto 

oon,..]Iod   to  -si     ^w.^    T      cTs    ";':'  '^^^r-ff  with  vertiVo,  ana  be 
par.  of  the   hodv.     Tlere\    s    am      Hm'"    /'    '"^"""•'•••age  from  any 

treatiii^r  hi,„„.|f  with     om  lU  .        r  ^''""'"  "'t<^™ittent.     After 

-;..  to  ha.     <l;;:e;it';- ;:m^r":;  1;.:^::':"°j;'t^  vi„ega..ancl  «alt 
"'"1  port  wine.     Tvventv-foiM-  v*>.  .■-  .       i     i'  1        ""'^  ''^'  ^  eruviau  bark 
h-  tio  «uppm-a.i„r     I  . :  "  ,  t  *;f,S/;;,f"^'  '^  ^--f '-'^'  «ore.  followed 
He  was' in  the  Jolico    S-oc  fro  ^  87  fr"^'"''  symptoms. 


-     tJl'^ 


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2  HENRY,   OSLER,    ATROPHY    OF    STOMACH. 

an  ice  wagon,  and  was  af'torward  a  ('al)-(l river.  Eight  years  ago  he 
had  an  attaek  of  gonorriiira.  In  187()  he  weigluMr.")!*.')"  pounds,  and 
was  a  pro?»iinent  ligure  at  a  "fat-men's  hail."  His  lieiglit  is  six  feet  two 
inelies.  Jn  LS77  lie  hegan  Ut  grow  thin,  and  eontinued  to  lose  flesh  at 
the  rate  of  one,  two,  and  three  pounds  daily.  lie  was  in  the  habit  of 
weighing  himself  on  the  same  scales  in  a  shdp  in  his  district.  He  oiicc 
during  this  ])eriiul  of  rapid  dimiuutioii  of  weight,  Inst  seven  pounds  in 
twenty-iour  hours.  This  loss  of  Hesli  continued  with  intermission.?  for 
eight  or  nine  months,  until  his  weight  was  reduced  to  147  jtouiids,  when 
he  began  to  regain,  and  in  a  year  thereafter  weighed  IMO  pounds.  The 
jiatient's  memory  of  the  exact  dates  of  tiiese  lluctuations  in  his  bodily 
weight  is  not  alwdutely  accurate,  though  sutiieiently  .so  for  the  purpose 
of  this  clinical  history.  lie  attributed  his  lo.ss  of  "flesh  to  indigestion. 
At  the  period  referred  to,  he  was  in  the  habit  of  vomiting  almost  in- 
variably after  taking  food,  and  was  fre(|uently  obliged  to  leave  the 
table  liastily  on  this  account.  His  weight  at  time  of  adnM.ssion  was  l.'JO 
pounds. 

His  skin  possesses  the  peculiar  yellowish  pallor  that  is  almost  pathog- 
nomonic of  pernicious  anuMuia,  and  the  ocular  conjunctiva  is  of  tlie 
characteristic  yellow  hue,  w  Inch  diilers,  however,  from  the  tint  of  icterus. 
The  palj)ebral  conjunctiva  is  milky-white,  apparently  bloodless.  The 
skin  of  the  abdomen  is  flaccid,  and  easily  gatht-red  in  folds  by  a  grasp  of 
the  hand,  which  fact  is  corrobonitive  of  the  ])atient"s  statement  regard- 
ing his  former  obesity.  This  statement,  however,  is  proved  bv  the  best 
])ossible  evidence,  that  of  ])hotogra])hs  in  his  po,sse.«sion.  His  girth  was 
once  iifty-two  inches,  and  is  now  thirty-two.  The  patient  dates  his  ill- 
ness  from  a  ])eriod  about  eight  wee'us  prior  to  his  admi.ssion  to  hospital. 
It  began  with  dizziness,  nausea,  jjulpitation  of  th-'  heart,  and  a  sense 
of  great  weakness.  These  symptoms  have  continued  up  to  date  of 
admi.«sion. 

The  results  of  physical  examination  are,  for  the  most  part,  negative. 
The  heart  sounds  are  very  feeble  and  distant,  and  unaccompanied  hy 
murnnir  or  hruh.  The  lungs  are  free  from  any  sign  of  disease.  There 
is  neither  tenderness  nor  increased  area  of  dulness  on  percussion  (jvcr 
liver  or  spleen.  There  is  decided  tendei'iiess  over  midiUe  of  sternum,  and 
a  tender  spot  was  al.so  found  on  one  of  the  lower  ribs  when  making  jht- 
cussion  in  the  splenic  region.  There  is  no  enlargement  of  the  Ivmpiialic 
glands.  The  tongue  is  exceedingly  pale  in  the  centre,  with  piuk  edgf.'r 
and  tip,  but  without  fur.  The  urine  contains  a  minute  trace  of  albumin; 
its  reaction  is  acid  ;  its  specilic  gravity  1.020  ;  it  is  free  from  sugar  and 
bile  pigment.  On  June  10,  17,  and  18,  the  temperature  rose  above 
normal:  on  the  first  of  these  dates  to  101",  and  on  the  two  latter  ti) 
102°,  in  tlie  evening.  After  the  18th  the  temperature  was  normal,  while 
in  hospital. 

June  17.  First  examination  of  blood.  Nund)er  of  red  globules  ])or 
cubic  millimetre,  7!)0,000.  Troportioii  of  white  to  red,  1  to  l."),S.  The 
percetitage  of  red  globules,  as  compared  with  'he  normal  nunibtr 
(5,000,000),  that  is  to  say,  the  "  hsetnie  unit,"  is  15.8. 

The  majority  of  the  globules  are  larger  than  normal  and 
thein   are  j)ear-shaj)ed 
qmxntity.      Hchultze's 
tested   Ijy  (jlowcrs's  hi 
amount  of  hannoglobin 


and 

oval 

111  ^.  jfii ^»- 1   II 
Microcvte 

ifiji  1 

nil  Ml 

sent 

111      iUlll 

in  con 

:iKtii 

sider 

\      HI 

ihk! 

gram 

le  masses  S( 

antih 

•  present. 

The 

coloi 

,  as 

eniog] 

ohiiK 

)meter, 

is  1(! 

l)er 

cent 

;  there 

fore. 

the 

1  is  re 

lativ 

ely  normal. 

This 

is  a 

cardina 

I  feature 

ars  ago  lie 
loiiiids,  and 
six  foot  two 
(ISO  tlosh  at 
the  habit  of 
:.  He  onco 
1  pounds  in 
iiissions  for 
iiiiids,  wluii 
uiid.-j.  The 
1  his  Ixxlily 
till'  [Jiirpose 
in<liL;ostii)ii, 
;  alino>t  iii- 
I  leave  iho 
ion  wa.s  l;)0 

lost  pathoLT- 
a  is  of  tlio 
t  of  ic'torns. 
dless.  The 
v  a  irrasp  of 
lent  regard- 
by  the  best 
is  <rirth  mus 
hues  his  ill- 
to  liospilal. 
nd  a  sense 
to  (hite   uf 

•t,  neirative, 
n])anie(l  l)y 
use.  There 
'ussion  over 
crnnni,  and 
nakintr  per- 
a  lymphatic 

pink  edi;e^ 
jf  albumin ; 
1  sugar  and 

rose  above 
I'o  latter  to 
•  rmal,  while 

■h)bules  per 
.  lo«.  Tiie 
lal   nundjer 


HENRY,   OSLER,   ATROPHY    OF    STOMACH.  8 

i;L5s;;tior;^;.,^;,:^:;:;^^     frT'  ^'"M-centago  of 

it  K-nerall  V  e.|uals  fro.  i  oh    ve     1       '  M     T"    ^"  l"'''"''''""'^  '"uemia, 
to  1.0  double,  llmt  i^f  tKhl- d't;:^;:"'  ''^'^  ''^*'"  ^''—1  '"y  i^^^^^^^^ 

A  largo  homorH  a^  r   he   ,        '  ;;m  ;;1  ''-"'^^  "'^  -- of  arteries, 
disk,  an.l  a  mon-  nnrnt  ,    o        '  ..  "'••'"'•"•'^f  -  "as  seen  above  the 

<l-k.  in  others  <.f  a;;:     .n-  -    !  "       l"f  "rm'*''"  """  ''"'^^   ''"'^^ 
^■""  "■"'  inclined  to  hi  tortuous      T  J  "  "l»P''- v<'>"  was  verv 

(initoccar.     The  oonditim.  i<  H,.,f     ,.  '"-   '"'''^-      -^'o  modui  were 

10(1  globules  varv  greatlv  in 


i       I 


and  ii-iTKiiliir.  '"'ii,  .4.     („l,„,iH.     Ololniles  al.uomallv  1,,,'ge 

I"'  had  a  deeided  chill  P,,  11  >  I  '  i  P'^'^'F  ^''^^  "'•'-^''t.  about  1..S0, 
l-'^pin-g  slightly;  ninperalu^^.?^^^  'S2^;C:>}''^  ^'^-.'"'^  --i 
evory  throe  hours,  and  suppository  of  lu  If  a  r  i  'Vh  ^  ■'''''  '"^^^' 
lI"-eo  hours  until  diarrh.oa  is  oiiockod  ^  "^'"  '''l"  ''"'"^^ 

^in™  ».  when  la^;'™pV«iS;Z';:;;|''"  ^«"-'>  ^  "■■-'  «  -  M.    .None 

;|.-a.  i«  nnnarkublo.--    N;,;;,l',';J'',,'i" '"tr.',".?.'!'!  '«■'■■"  ""»'*  "'_■«»' 

slia 


inber  of  rod   globuio.s  ]wv 


ol>i'lcs,  for  the  most  part,  nnioh  larger  ih 
'pes.     IS o  M-liite  in  specimen.     II 


-W(.  Num 


0.  ni.,   l.ti.So.ooo, 
im  normal,  and  of  irroLnilar 


verv  hi 


)er  of  rod  globules  [)e 


■ge,  some  of  thorn  throe  times  the  normal 


^omic  u.iit,  ;}2.r).     Color,  40 
I-  f.m.,  1,()()5,0()0.     (ilobul 


111  shape ;  a  few  mierocytes.     H 


icmic  unit,  32.     Color,  80.    Th 


les  mostly 

size,  and  very  irregular 

c  count  is 


llii 


1 
3 


■:  1 


;-.'i 


■iM 


HENRY,   OSLER,   ATROPHY    OF    STOMACH. 


almost  tlio  same  as  tlie  last,  although  tlio  i)atient  feels  decidedly  better, 
and  walks  eonsiderahle  (iirilaiiees  without  i'ati<j;ue,  in  spite  of  the  intense 
heat  now  ])revailing ;  the  thermometer  to-day  reaehed  100^  F.,  in  the 
shade.  His  aj){)etite  is  good,  and  tlie  bowels  are  moved  once  dailv. 
Ordered  ferri  jjyrophosphat.,  gr.  iiss  icv  in  die. 

Aui/.  Z  (Sunchiy ).  On  Tin. i.sday  patient  came  to  have  his  blood  ex- 
amined, but  it  could  not  be  done  at  that  time.  On  his  way  home  he 
drank  a  glass  of  buttermilk  and  soon  after  swallowed  a  [)late  of  mock- 
turtle  soup  and  a  glass  of  lemonade.  The  conseipience  was  an  attack  (if 
cholera  morbus  the  same  evening.  He  treated  liimself  with  laudanum 
and  blackberry  brandy,  and  by  next  day  the  attack  hail  ceased.  On 
Friday  he  weighed  1:!5  pounds.  Number  of  red  globules  per  c.  in,, 
].()40,0()().  Hiemic  unit.  ;!2.8.  Color,.'}!).  Average  size  of  corpus.!.  > 
still  decidedly  above  nornuil.  Very  few  microcytes.  No  granule  masses. 
Shape  of  globules  less  irregular.     No  whito  cells  seen. 

lOfli.  About  the  same.    Jilood  not  examined.    Hydroleine  prescribed. 

i-7//i.  Feels  iiuich  better.  Weighs  140  pounds.  Talks  of  getting  to 
work — cab-driving.  Has  walked  a  distance  of  two  miles  without  latigue 
during  the  jjast  week.  Appetite  good  and  bowels  regular.  Did  not  take 
hydroleine,  but,  by  advice  of  an  officious  friend,  took  elix.  ferri,  (luinia", 
et  strychniie  i)hosphat..  instead.  Numl)er  of  red  globules  ])er  c.  in., 
l,80r),000.  Hiemic  unit,  of).  Color,  o'i.  No  white  seen.  Patient  lo<jk.s 
very  pale  and  ghastly. 

*SV';;/.  :■.'.  Has  been  working  as  a  street-car  conductor  for  a  week, 
getting  up  at  o.oO  a.  m.,  and  working  until  late  at  night.  Cot  alnn^r 
very  well  until  two  days  ago.  when  an  attack  of  diarrha-a  compelled  liini 
to  stof)  work. 

IStli.  Working  again  as  car  conductor.  Rises  at  4  A.  m.  and  dues 
not  get  to  bed  until  one  o'clock  next  morning.  He  has,  therit'ore,  if 
his  statement  is  correct,  only  three  hours  in  bed.  "  Never  felt  better  in 
his  life,"  but  looks  exceedingly  ])ale  and  thin.  No.  of  red  globules  ]nr 
c.  m.,  1,47(1,000.     Ha'mic  unit,  20.4.     Color,  ;>"). 

Oct.  ^1.  No.  of  red  globules  per  c.  ni.,  1,2.")."»,000.  Ha-mic  unit,  2"). 
Color,  20.  White  corpuscles  to  red  as  1  to  500.  Globules  large  and 
irregular.  Patient  complains  of  great  weakness  in  legs  on  walking  slmrt 
distances.  Has  bee:)  continuously  at  work  as  car  conductor,  though  nut 
on  full  time. 

Nor.  /!>.  Sent  for,  and  found  him  lying  down  thougii  (lre,<sed.  Ila.s 
not  worked  for  a  month  and  is  exceedingly  feeble.  Has  followed  no 
nfgular  treatment  wliatevcr,  being  incorrigible  in  this  respect.  Ila.'^ 
taken  lately  some  pills  called  "  tree  of  life,"  which  purged  him  fnilv 
and  reduced  his  little  remaining  strength.  He  complained  of  ditHeiilty 
in  ])assing  water,  and  stated  that  some  years  ago  he  had  been  treated  fur 
stricture  by  the  late  J)r.  >[aury.  J'a.s^ed  a  No.  1  ">(  French)  cat heti  r 
and  drew  otf  a  little  limpid  urine.  No  bhdd  followed  passage  of  ii:stiu- 
nient.  (About  ten  days  later  No.  21  was  passed  without  difhculty. )  His 
quarters  are  very  contined  and  (hirk,  and  exceedingly  noisy  from  ceii- 
timnd  pas.-<age  of  Pi'iinsylvania  Iv.  1\.  trains  almost  directlv  overhead. 

Dcf.  JO.  Sent  for  late  at  night  on  account  of  ahirnnng  dy.-j.iKi'n, 
When  visited  he  was  relieved,  the  relief  having  succeeded  the  lielcliiiig 
of  large  iiuantitics  t)f  wind. 

I7th.     About  the  same.     He  had  apparently  sent  to  iiupiire  whcttier 


ther..   \ 
and  li(j 

him  coi 
adniinis 
^\•atery 
liipior  f( 
not  retii 

cxamiiiii 
tlirice  di 
On  J:, 
initted  t 
l)een  exc 
utter  ])rc 
lOtk  ] 
partially 
eighty,  "vi 
sighing. 

Nil  in  Ik 

pale  tint  ( 

was  made 

info  the  I( 

and  'lowei 

cliloride, 

Himt,  Ca 

clo,«e  of  til 

tlie  greate 

c'Hild   not 

cliani^'cil   ii 

''<.-'!0  ■  I'.  M., 

ililated  ;    p 

lahored  ain 

Aiifoj).'<ii, 

iihle  ennn'i; 

liiilf  an  inc 

■•'liiii  and  al 

ln'i'itoneuni 

'listeiided   w 

covered  wit 

'hu'd  in  cav 

liiiiinary  im 

.vt'llow  clot ; 

•'I'W'ly  adhe 

«cre  eoljeet 

fMipty;  snia 

tioii  of  the  h 

evidently  fat 

i'tln'i-omiitoii.' 

"lit;   the  '   ,, 

tlie  adhesion.'- 

tiihcs  an;-  tra 

>^plrc)i  is   sj 


HEXHY,OSLER,    ATROPHY    OF    STO.r.Cir  g 

"'l""'".t(T  ars..„i,..     The  diMrrl  ,  '.   u  I  "''""'•'^'  '•'■^"It  .,f'  attempts  to 
watery  .tool.,  was   c-lu-eke       ,       Jft,    ,'': 'r"'''!!'!"' /''  «<^ven  or'ei.I 

"*'t,  'vfn-n.         '        •  ^  ^-  ^  '"  '"  '^'^',  to  hegni  to-inorrou',  if  .liarrluea  do^l! 
~'W/.     E>.('oc(lin,2:ly  nale  and  feeliln      V 

i^'J^'^i/t.!:^- ,;■;„;;  :;r;:;x':/:.;:;;!;;r-  ^•"-  -•'-''  1-  eo„,., ,« 

^■^^ty,  very  snmi],  soft,  and  c-on,  .re^i   l    ^    f  ,""^'  I'^i'^''^     The  pulse 
•^'^^'"",ir.  prcssiDii ,  and  the  respirations  deei'  and 

Nninl)er  of  red  ololMiles  per  e  ni    1)-^)^      /.    • 

'"'"'  ^'"i  "^  "';■  '>1"-1.  the  color  ;.■;;]', ''r.t  h     ""7  "  1'"^  "^■^'•^""*')^' 

)VM.s  nia.le  at  throe  o'clock.     At  i nlf         V       A  ''"'I'loyed.     The  count 
'"^!''^'  '<■«  iMt.rnal  saphen,  I  -e      l^  ,  r;\  '"  ^  ■".)-f«"« 

'":'    ";v'''-  tl'inls  of  the  le-  fifti     fl   ;-  ^'"V"»''t>""  of  the  n>i.|<lie 

;;'-  of  the  •:;::.!,.:;;:  ^d^ ';;  .-.-ii^^viue  Hor.it. ^^i -;,;,^;;:;; 

tlu"  irreatest  skill,  the  patien  I.eea  e  .o:^,,  '"■','  """^  I""'-'i>nu<.d  with 
7"''l  ","t  reply  to  .,uestions.  P  ^1,?  "\";''' A''*^'"*'"'  '"'■^  ''Xcs,  hut 
;;l:;.ni:;'.l  m  ft-e,,uency  (80),  but  „„'  h.^  f  I  /' V  'T'^'''''"'  »»- 
':■'<  V^'-  !'=''"'"t  i"  condition  of  le/vv  1^'  '''"•'"'  "I"''''"'""- 
''"^•'"V  '''''^^'  ^'.vt-vn.elv  weak,  hut  st  lY  8(  '  =  '•"'"'■'  '".'.leratelv 
''•'■";'7'  "'"I  fi.u■lii...^  hut  not  .t(.;  us  Di,,f  .';'■,  ?'':"f  ^  :  respirati,,;. 
,-'"''^/-7/.  i'lcvvn  hours  after  de'  P;  "^  '-•'*'*'  f""''  '"""••^  I'Uer. 

;'l' ^'"".eiation.     (;i<.atrie..s  on    d^   ^  .Jl  f'"  T''^'^  '-"-"t-     <  oMsider- 
''•'If  '",  inch  in  thickness;  fiit  of    V^^^^^  Pannu.ulus  not  n.ore  than 

^'^'"  "•"' all  organs.     JM     f  !^  t     1^7  T^T     ^^'-^"''^  P'^'lor  of 
;;r';'""-l"'  -'-ooth  ;  sn.all  an.o  nt'o  ';     .  r  •  li   ■  "^^^"r'"^'  ^"'"'''/' 

'''■^ten< led  with  j-as.      fn   nV/A/  Jr^-a  —A^^^l"^ ''r^'''' '  the  intestineJ 
"^■'■'•e<l  with  a   moderate  •ino..,       >f  ^'^'"/ ''^'.  "'"x'^"'".-.     Pencnlium 

''"'"""•.^' "'<'''^'<'<'s  show  in  Wo-.t':,   ,i.  "V^  *"  '-  ""^'"--^  «accid;  pre- 

■T"'?^-  ••'"t;   in  rio-ht  ventrd    a    .]!'"' '^^rr'-*''"^  »  lar^c 

••I'-ly  adherent  ^.' trahec.d^  a  „i\.  ^  "V"'''^'  ""'"'•"^"I  ^^'th  s<.rum. 
"'■'•"  •■""''•■t'''l    fron.   these  S  tL    1  l^^*'''^ 'I^  "  ^^'^f^'O'  ''l<.od 

™'"f^-  " "  "■•       ■        ■•  '"'"""• '■^-      llu'  left  (■hMnd)ers  Avere  nearly 


'■"",  "f  the  heiu-t.  walls\.f 


"'"•nial  thiel, 


.'"itral  orifice.     On  further,] 


isse 


-..lH.tly  tatty  :  ,.i.ht  .handie         .;  1,!;;;:;^ ''""-'^  very  anuMuic,  an,| 
iltl croniiit.iiic. .  '^'   ""''led  ;  valves  iim-ni.il         i    .  .i 


iitlicroiiiaton 


out;    the 
tlic  adhcsi 
till 


;  "^'oronary  arteries  healthv.     /. 


valves  normal.     Aorta 


ivcr  lohes  y 


«»ns  which  exist 'het 


ciy  o'dcmatoiis.  and   tl' 


"".7'^' pale,  crepitant  throunl 


not 


"■■^  anu  trachea. 
iSjili 


^■wii  the  lobes;   f'rotl 


nfilt 


ration  extends   t( 


''"  '«  .'-liglitly  enlarge.1,  nunleratelv  fi 


nil : 


'.V  iiuicus  in  hronchial 
piiip  of  a  deep  puri)le- 


(     i 


i 
1 

I.' 
p 

1,  1 


•\i 


\\\  i> 


rill 


6 


HENRY,    OSLER,    ATROPHY    OF    STOMACH. 


w    IJ 


B 


!;i 


red  color ;  the  jMalpi^^liiaii  eorpiiscles  not  evident.  Kithici/n  of  normal 
size;  eapsnies  detaeli  readily,  surfaces  a  little  roii^di  ;  on  section,  cut 
with  increased  resistance;  cortical  Mortions  pak';  small  arti'i'ies  at  hases 
of  pyramids  very  prominent.  The  ■•<iijir(iriiiii/  cd/iKti/cs  are  of  averiiLii' 
size,  tirm  ;  cortical  portions  of  a  deep  yellow  color.  Bladder  contains 
several  ounces  of  clear  urine. 

>St()iii(ich  looks  natural,  contains  y'as  and  ahout  an  ounce  of  dark  fluid; 
pyloric  orifice  firmly  contracted,  and  the  ring'  seems  tiuckened  ;  cardiac 
orifice  normal;  lentith  of  orj^aii  eleven  inciies;  breadtii,  when  opened, 
eight  inclies.  Walls  not  increased  in  thickness;  at  fundus  two  to  threi! 
ndllinietres,  at  middle  of  anterior  wall  two  and  a  half  to  threi  iiiilli- 
nietres,  and  at  ])yloric  zone,  ten  centimetres  from  thi'  ring,  eigiit  to  nine 
millimetres.  General  surftu't;  of  mucosa  jmle ;  mucus  covers  the  ])yloric 
region  ;  there  are  a  few  dilated  venules  in  several  places.  At  the  fundus 
the  nnicous  nuMuhrane  is  very  thin,  smooth,  grayish-white  in  color,  tough, 
and  teai's  with  ditliculty.  No  trace  of  superficial  softening.  Jn  tlir 
middle  zone  it  ''as  the  same  pale  gray  as])ect,  is  smooth,  and  there  is  an 
entire  ahseiu'c  of  the  velvetdike  appearance  of  the  healthy  mucosa. 
About  the  middle  of  the  lesser  curvature  there  is  an  old  cicatrix,  phunlv 
shown  by  four  or  fivc>  radiating  lines,  In  the  pyloric  zone,  the  nnuMi.-a 
is  more  vascular  and  decide<lly  thicker.  Scattered  over  the  surface  nf 
the  membrane,  particularly  in  the  central  zone,  are  numerous  smiill, 
grayish-white  elevations  the  size  of  a  pin's  head,  most  of  them  isolated, 
others  in  groups,  and  contiguous  ones  ari'  joined  by  narrow  iiius  nf 
tissue  jjrojecting  half  a  millimetre  above  the  surrounding  sui'tiicc 
Toward  the  pylorus  there  are  larger,  more  flattened  elevations,  separated 
from  each  other  by  shallow  areas  of  a  pale  gray  aspect.  With  a  low- 
jMiwer  lens  small  orifices  can  be  seen  in  these  flattened  elevations,  and 
here  and  there  in  the  smaller  nodular  {jrojections  little  orifices  and  ;iiiv 
cysts  can  also  be  seen.  The  general  surface  of  the  muco.sa  as  exs.niiutd 
with  a  iiand  lens,  has  a  smooth  cnticidar  appearance;  the  thin  mucosa  i> 
readily  movable  on  the  muscularis;  the  sid)MUicosa  does  not  appear 
thickened  ;  and,  with  the  exce])tion  of  the  j)yloric  region,  then  is  no 
thickeiung  of  the  nui.scular  coat. 

The  (esophageal  mucous  glands  are  unusually  di.stinct.  /)u(Kl<innii 
contains  a  bile-stained  mucus.  Bile  Hows  freely  from  the  orifice  of  the 
<luct  on  compression  of  the  gall-bladder.  Siiki/I  iiili.^tiue.-t  contain  a  thin 
nnicus.  The  walls  of  the  jejumim  look  of  average  thickness;  those  uf 
ileum  thin.  Peyer's  gland,  in  the  portions  examined,  nornuil.  The  larije 
bowel  was  not  opened.  JJri'r  looks  large,  is  of  a  light  yidlow-hrown 
color;  capsule  ])resents  patches  of  thickening.  Tissue  cuts  easily,  and 
contains  very  little  blood,  (iall-bladder  distended  with  pale  bile.  /'(//- 
creos  very  large,  weighs  more  than  100  grammes  ;  looks  natural,  lohulcs 
distinct;  on  .setrion,  presents  a  very  normal  a|)pearance.  Thunwir  i!iirt 
normal.  The  thonirtc  and  ii.-inili(ii(ir  i/<uii//l<i  have  a  natural  ap|icaiiinci'. 
No  enlargement  of  the  boiicg.  Marrow  of  ribs  and  sternum  of  a  dceii 
purple-red  color.  That  of  lower  portion  of  right  tibia  lymphoid,  tlu; 
canceihe,  at  the  end  of  the  bone  contained  fat. 

Brain  not  examined. 

HisToi-()(ii(  Ai,  K.XAMiNATKix. — St'»n(ir}i.  Portions  were  taken  finni 
four  dillerent  parts  and  hardened  in  alcohol.  (1)  From  fundus,  win  iv 
the  nmcosa  looked  thinnest  and  ha<]  a  very  smooth,  cuticular  appi'iu'- 
auce.      Entire   thickness  of  suction  about   3.5   millimetres,  of  which 


t. 

»  of  normal 
section,  cut 
•ics  at  ha.S's 
of  avcniuc 
ier  contains 

"(lark  fluid ; 
c'd ;  cardiac 
lien  opened, 
;\vo  to  liirec 

three  niilii- 
Ldit  to  uiiie 
*  tlie  pyloric 
t  the  fundus 
L'olor,  touLili, 
njj;.     Jn  the 

there  is  an 
;hy  nuicosa. 
trix,  plainly 

the  nuu'd.si 
le  surface  of 
erous  small, 
L!ni  isolated, 
o\v  lines  of 
intr  surface. 
IS.  sc|)a rated 
With  a  l(i\v- 
vatioiis,  and 
.•es  aM<l  ;iiiy 
.IS  exuniiut  il 
in  nnu'dsa  is 

nut    appear 

there  is  no 

I  )ii(tdiiniiii 
I'itice  of  the 
ntaiu  a  tliin 
'ss;  those  of 
The  lafLM.' 
ellowdu'iiwn 
i  easily,  and 
bih'.  '  ]\in- 
iiral,  loliules 

luifftcir  (lild 

ai)pearaace. 
n  of  a  deep 
uiphoid,  the 


taken  froiii 
lulus,  where! 
liar  appear- 
•i,  of  wliicli 


HEXRY 


OSLER,  ATROI'lIV    OF    STOMACK. 


^;:;;M?:.r;d;';u::j 

"!•'».  the  nniscularis  un^^^tuVr^,  the  .scrfon.  hut  i.uuu.diately 
tened  an,l  sn.all  roun.l  <'d  on  h  ],  ,H  ' an""'  r!^'"'  ^^''-  '^'  ">  ••^'  "'^^ 
^ta.ne,  preparation  the  mucK  n  I  ' '^  ,^' ,  j!*  jf--';  "-^''i^^-  In  the 
im;  feebly  marked.     The  muscnlaris   ..n?  '''«t'>i<'t.  but  the  outlines 

ti«>"-  There  are  two  <li  i  •  a ve  i  "''  ''"'"•'  '''  '•'■"''"•'<"'''*"  alteru- 
='••0  cut  h.nirit.Hlinallv  a,       ;,,'.,         •       "'"^''•""•^t  "^  "hi<.h  th,.  eells 

t.;  hftcen  nn.sele  (vlls  ,,„,  ho  c<  u  fe  1  S'  ti'  ' ,  '-•,  -'  '  '•  ^''■'""  t"<''v« 
"■'"'t  i"  fl">kne.ss  in  .liff^  e  t   ,h    ^         ^^^-fd,  which  varic-s  son.o- 

Fifl.  I. 


H  tHjiil  .(...  n.M.ihii-  iin.,«t;>,i,s,  f,,  (,;  c,  rcnumnt-.  „f  fnl„,i  ,    '  "'  '""'""»  mcinhvano 

'" ^'"'" '■'""•  ^ ■""--  ouna,.A.  o,j.r;r:i^/ivt;~''''  '"""•*•-'"'«>- 

;:St 'i;.;;"';;/ 1;;;;;^,,:;^;;,,;|-';  -^---V  ami  in  places  there  are 

<■  i>-i  'n-  ^,y  I  pi  events  coarse  fibre 


j 

i 

1 

ill 


I."* . ,,      hi 


liltri-s  cij 


t  lony;itiniit)iiiI.v  ;  c 


lumiUoB  ;  df  Iicgimii] 


1. ............  /.  ...l.._     4  <  ..   ! 


SllhUUU 


I  yisth  \J\.  111(11     ^^ 


ibtifi.tif't  li 


iiicli. 


Kin    ti 


-V        |N     t' 


-ft' 


ni(|  Xu.  s.    -I, 

tH  of  the  pi'plic 


"EXRY,    OSLER,   ATROriiy 


OF    STOMACH. 


<'ell.s  and   is  Iim.-oIv  ('(minw.f,.,!   f     *i 

'I'^^HocollH  d„  not  look-    ;:i  ;.;?-J;,.^,;';;'  f'  ^'I'Ih...'   nonual.     Tlu, 
^fe^"-l  ns  thos.  i„  tl„.  nn,s,.ulari;  ;,";;;,;;^'  ""•    "'  '''^^   ^^"""■''  "-  "dl 
\^)    1  ortloii  oftlic  inl.1,11,,  ., f.i.     ■     ■         ,    . 


tl.o  lon!.it,Hli„allv  rut  l.am     friCf  .k''"^'  <'*'"?  "'"'  "''"^'^  ''i'-'-f'v 
soction  ].  '  '"""'    '"'^    *'"■  !>l)IH"iraiKv    (IcsrrilM'd 


Ill 

'Ctl 

in 


I     I  •""  I'"  I'll  i'OM(U'ra 

'"I'y  lit'iv  and  there  notic."d(l..      'I'l„.      n      l-   . i-m-"  '^"■' 

"'<■  <->'tn,l   portion  of  ti  e       'iev  f      '     '  "^  ^''*'  '"''"'"''  '""'<  ""•■"'"I  i- 


under  (,!,.  ""^^^  ''"*"  '"  llie  ^eetions  desorilu'd 

F'.ir.  4.  '^     "Diiitunal  j.r.difemtion,  as    rei)rt«i.nti'd   in 


J5it8  of  tl.o  fresh  MHioosafn 


""  various  parts  wore  teased  earofullv  in  salt 


•1  ti 


10 


IIEXKY,   OSLER,  ATUOPHY    OF    STOMACH'. 


solution.  Except  in  the  ])ylorit'  zone,  no  tubnlcs  or  cvlindriciil  cpitlu'liiini 
were  i'oiind.  In  sonic  of  the  nodnhir  projections  renmiints  of  uland  tissue 
and  ii  few  colunniiir  cells  witc  seen,  (ientlc  .scrapinus  of  tiie  surface  and 
the  teased  bits  show  a  hirgo  luiniber  of  ttuttened  cells,  unlike  anvthin<f 


Fia.  4. 


.'<c('(ion  (if  a  Hiimll  artery  in  siilnimcosa.  a,  stniina  ;  h,  ailvciititia  ;  c,  iimsnilaris;  J,  rlastii'  laiiiiiiii 
of  intiriia;  e,  iirnlifcraticni  of  suln'n.kitliulial  conouctivi'  ti.-suf,  lesilltiriy  in  almost  i-oniiiletf  oliliti  ra- 
tion of  tho  luMiun  of  the  vessel. 


V  i   ? 


Pi:  J 


ii, 


met  with  in  tlio  normal  mucosa.  They  are  irrcLnilar  in  shape,  lonjzer 
than  broad,  with  uranular  protojihism  and  central  nuclei.  The  aveniL''*' 
mciisureiuents  of  a  numlier  tiave  j.jVt)-  to  ^i,^  of  an  inch  in  lenjith.  and 
TTs'eff  to  xinu  '>^  ""  '"'■''  '"  breadth.  Some  of  these  arc  rcmarkahlv 
lonjr;   mcasurenients  of  four  o-ave  ij^iy,  ^pV^ 


1 


and  jijv  of  an   inci 


and  from  ^^^  to  yo^oJT  ''^  ""  '"^'1'  "'  l)readth.  Many  t)f  the  ceils,  par- 
ticularly in  the  pyloric  rciiion,  look  like  swollen  ulandidar  epitluliinii 
of  the  peptic  follicles.  Flat  ribbon-like  muscle  cells  are  numerous  in  till 
the  portions  examined,  and  there  is  a  distinct  fibrous  stroma  thickly 
beset  with  cells.  Throughout  this  there  arc  in  places  jjroiips  of  rounded, 
translucent  bodies,  resembling  the  amyloid  corpuscles  met  witli  in  dc- 
generatiiig  tissues. 

Sections  of  the  (liuidciiHin  show  many  normal-looking  tubules,  but 
here,  too,  the  amount  of  iutertubular  ti.<sue  seems  excessive.  Brumier's 
glands  look  healthy. 

I  nfortunately.  by  an  oversight,  portions  of  the  jejunum  and  iUiiin 
were  not  reserved  for  examination. 

Pdncrcnu.  Cells  of  the  acini  very  granular,  but  otherwise  normal:  in 
])iaces  there  are  dark  brown  pigment  grains.  Tiie  interaciiimis  con- 
nective  tissue  is  slightly  increased. 

Heart  iir.iisv.b:  very  fatty,  but  llie  degeneration  is  inuMpially  distriliutcd, 
as  ia  evident,  indeed,  macroscopically.  The  brown  jiigment  granules  an 
very  abundant  in  many  lilircs. 

Liver.     Cells  distinct,  moderately  fatty.     Small  brown-red   pigment 


HENRY,    OSLKR,   ATROPHY    OF    STOMACir. 


11 


jrrmnsyn-ynl.„„,la.U  both  i„  tin.  ^landc.c.ll. 


t'lfinciiis. 


Kid, 


'ifi/s 


Kpid 


iind  in  tin.  c'oiuioftive  tissue 


fatty,     til,.  ,v,|,|i,^| 


'.'"•'"'.''1  of  cnrticiil  i.„rti 


pi.iiiiu'iit  ^iiimilcs  ill 


HOMu;  ,.f  tl.r  .-ulJirtiiifr  t,,l)„los/ 

IK-  marrow  prosonts  the  usual 


>'is  swollen,  and  in  pla 


•e  very  nimicr 


■intiiolnini  of  the' L 


•oll.- 


ees  verv 
'"til  in  the 


The  />o 


:>ps  of  llcnl,.,  and 


111 


IS  very  little  fat ;  the  mar 
I'iift,  lint  the  ord 


•o\v  ee 


i; ;;::'":;;:{ ":i'r'T^';''?  "•■". "-i-.;.  ::;::i 


I";.; v..n.  ,,,^. o,,,.,ri„„.,,,,  ■  xu*,;;;;,;:; 


(•wistitnents  of  this  tissue.     There 
various  sizt-s  make  up  the  ehi,.f 


nianv 


)ers. 


Tl 


.f  tl 


and  til) 


lere  is  no  essential  diff 


contained  flit 


ii,  exeept  that  in  the  I 


fence  iietween  (I 


corpuscles  occnr  in   nti 


ist-named   hone  tl 


H'  uiarrowof  rih,  sternu 


leni 
m- 


in. 


"•ections  o 


and  an 


f  th 


It;  eaneelhe  at  the  end 


at' mi  I  mint 


v\('i'fi&  of  connective  ti 


1/(1  IH/f. 


lu  sh( 


T 


Sl-mm.\I{v — CI  in  lad.     II 


'sue, 


>\v  deeply  iiigmented 


nerve  cells 


cu  years  a;i'o  severe  (rast 


'•■^tory  of  diii,], 


Kiuir  hahits   for 


iiKU'e  than  nine  niontl 


iiianv  vearr 


fii'ual  diarrlKea,  and  irre<rular'f 
iii.!,'to;5]r,.00U,,crcul)icniill 


'•'esymptomswi.il   .^rvM  loss  of  ilHi  '   F 


]''  severe  synii)toms  of  ai 


ever. 


Aiinh 


'iiincK 


I.     10  xt 


unetrc 


T 


or 


or<''ai 


i«and  hyperplasia  of  tl 


ivnu'  auieniia,  with  tl 


■puscl 
iiusfusion 


"a'uiia,  with  nausea. 


or 
occa- 


uiemluiine   of  the  st 


)nuieli,  witi 


le  marrow  of  lony  hoi 


•  ieath. 
H'  usual  fattv  cli 


,n'eatly  reduced,  sink- 


tiil)ulesin  the  lar<rcr  i)art  of  tl 


uuieo.se 


'  eoniplctc  (K'stniclioii   of  tl 
"'"r-an.     Hypertrophy  of  the  m 


al  tatty  clian>r(>,s  in  the 

ics.    Atrophy  ,,f„|iicoiis 

le  secretory 


iiscularis 


JvK.MA 


HKS. 


-Th 


e  patient  with  the  {\ 


)ro;,M-essive  jiernici 


a  vivid  jiicture  of  | 

pivsent  in  hold  relief:  the  exces.si 

fi'ver,  th(!  retinal  1 

tlie  iiumher  of  tl 


''•<',u'"iu,t;-  clinical  hist 


K'lis  aiuemia.     Everv 


ve  pallor  and   prostration,  tl 


ory  presented 
iui)tt)m  was 


sv 


u-morrlia,!.es,  and,  above  all   tl 


10  aiiiemic 


w.   re( 


1  -dol 


porfm,   of  hiemo^lobin,   the   al 
globules  (poikilocvt 


"lailt's,  with,  at  tl 


,  tlie  extreme  reductioi 


1  in 


le  same  time,  a  i 


teratioiis  in  the  s 


()SIS  > 


'"""""t-     The  most  promin 


and  the  j)resenee  of 


ize  and 


Sli 


iormal  pro- 
ape  of  the 


Uiicrocytes  in  abnormal 


disturbance,  due  to  the  in-oloni:eil  al 
uution  of  weij.dit.     In  less  tl 


^■"t  symptoms  were  those  of  profbun.l 


"ise  of  alcohol. 


a?!/' 


liunilred  and  tift 


lian  one 


the 


nieious  aiuemia  to  wliiel 
ar  cases  have  been 


y  pounds.     This  is  1 


.var  the  patient  lost  more  tl 


irastric 


rapid  (limi- 


Siuii 
iiaji:ei 
.f  th 


li  ^rastric  disorder  stand 


>.v  no  means  the  fii^t  case  of 


um  ono 


j)er- 


o 


reported   by  1 
■ou<rh  which  a  bright  light  has  b 


'  thr 
is  hitherto  ol 


enwu 


k,'  Q 
'wn  thrown 


s  m  causative  relation. 


is  now  taken  to  the  ind 


>seu re  disease,  and  it  is  for  tli 


nineke,'  and  Xoth- 
ipon  the  patholoo-v 


IS  reason  that  e 


xec 


to  eases  of 


'serimnmte  application  of  the  term  "idiopatl 


ption 


I 
It 


progressive  ])eriiicions  jm 


»e  regarded  from  aiiotl 


:eni.a.        he  rapid  loss  of  fl 


luc 


is  a  well-atteste.l  fact  that  fe 
iiinre  serious  import   in  fjeshv 


icr  point  of  view  ^ii.m  that  of 


.^crs,  inflaniniatorv  and 


those  of 


so-called   jile 


sparer  habit,  and,  in  explanat 


plethoric  individuals,  tl 
ioi:,  von  Reckliiml 


Atitiphy  of  tl 


csh  may 
symptomatology, 
essential,  are  of 
lan  in 
luiLsen*  susr- 


'  Deutschos  Arch 


licStuiimcli,  18-1. 


ivfiirkliii.  Mod  ,  lid. 


'  Viilkiimiin'e  Sii 
*  Deutsche  Chir 


iiniili 


iiiR  Klin.  Vortrago. 
igie,  1«SJ,  ltd.  i.  p.  18U. 


ri 


i  f 


i  I 


12 


HKNRY,   OSLER,   ATUOPIIY    OF    STOMACU'. 


;  ■; 


f    I 


frosts  that  the  nipid  ahsorptiuii  of  fat  and  tlic  |)r()(lu.ts  of  fatty  niota- 
iiiorpliiisis  may  jiivc  rise  to  a  iiiialitative  cliaii'rc  in  tlio  coiniuKsition  of 
tlic  hlood. 

'fill'  ('(inscrvatioii  of  tlu'  muscular  str('ii;rtli  is  also  wortliy  of  notice  in 
this  and  otiicr  cases.  On  Ani,nist  15  tlic  patient  walked  two  miles  with- 
out latitrue,  when  there  were  less  than  "i.OOO.OOO  red  <rloI)ulcs  per  enhie 
millimetre.  A  jtatient  of  Laache,  of  Cliristiania,  walki'd  three  kilo- 
Mietres  (more  than  two  miles\  the  entire  distance  heinj;  up  lilll,  wluii 
his  Idood  containeil  hss  than  1,000,000  olol)ulis  per  cubic  millimetre.' 
►Such  facts  iKvpiire  a<lditional  si^r'iiHeance  when  taken  in  connection  with 
the  dee|)  red  color  of  the  muscles  in  these  cases.  It  would  appear  ihat 
the  mn.scles  in  pernicious  amcmia  are  nourished  at  the  ex[ien>e  of  tlic 
other  tissues. 

All  attempts  at  treatment  in  this  ease  were  rendered  iHi<(atory  liy  the 
irritahle  state  of  the  intestinal  tract  and  hy  the  patient's  wilfulness  and 
])('rvei>it;.  i'l  re<rard  to  imitteis  of  diet.  LeaviuLr  out  the  lilood  exani- 
inatioi'.'  i.  vhicii  he  always  took  a  keen  interest,  it  was  inipossihie 
to  serin.'  i)i>  cooperation  in  any  diajrnostic  or  therapeutic  ))rocedure. 
Alth;  H',.li  ;• 'pcatedly  reipiested  to  .save  the  urine  secreted  durinu-  the 
whole  l\\eii(y-four  hours,  in  (U-der  that  its  percentaire  of  urea  mii:ht  \w 
estimated,  he  only  managed  to  do  so  once.  On  this  occasion  (,Iune  '_'<•) 
the  amount  was  4.5  oz. ;  sp.  gr.,  1 .01  •_' ;  i)ercentage  of  urea,  2.05  ( normal  . 
There  was  no  alhtimen. 

The  only  special  lesion  in  the  ca.se  was  the  atropjiy  of  the  nnicnus 
membrane  of  the  stomach.  This  was  evident  to  the  naked  eye  in  tlie 
thin,  cnticular  apjjearance,  and  was  abundantly  contirmed  hy  the  micro- 
scopical examination,  which  .showed  that  the  jiejitic  glands  had  heeu 
destroyed  over  the  greater  portion  of  the  organ.  The  iiunn'rous  small 
elevations  which  existed  in  the  middle  zone,  represented  areas  of  the 
mucosa  less  advanced  in  degeneration,  and  are  comparable  to  the  nodules 
of  relatively  normal  tissue  which  beset  t'.ie  surface  of  u  cirrhotic  liver. 
Toward  the  pylorus,  where  the  atrophy  was  le.ss  advanced,  the  various 
stages  of  the  process  could  be  traced,  consisting  essentially  in  a  small- 
celled  infiltration  between  tin;  tubules,  such  as  occurs  in  all  forms  of 
slow  inter.stitial  inflammation  ;  and  we  may  reasonal)ly  conclude  that  thi:- 
process,  extending  over  many  years,  ultimately  led  to  the  condition  here 
described.  The  only  other  alternative  is  the  supposition  that  ii  cree])iiig 
ulceration  had  at  one  time  involved  the  greater  part  of  the  mucosa,  with 
the  exception  of  the  little  islets  of  ti.«sue  already  mentioned,  and  in 
healing  had  left  the  membrane  in  this  state.  Tlu;  radiating  cicatrix  at 
the  lesser  curvnture  no  doubt  indicates  that  the  patient  had  had,  at  one 
time,  probably  in  1877,  when  the  gastric  symptoms  were  so  marked,  an 

'  Die  Anamio,  S.  Loailic,  Cliristiania,  1883,  p.  147. 


HKNRY,    OSLKR,    ATROPHY    OF    STOMACH.  13 

iMUn,.su.,  an.  not  , .ist  •,  H  i  '"""'''""'  "^^''"  ""-nluri.s 

•■''-•"tiv.  .1...  n        r      1  "''"^^''"'^'"'■^'  '■"••  '-•"  ^'^^tcnsivo 

wns  in  tins  ciiho  froelv  niuvMl.l..      \  '      '  """'""'"^  "lombrano 

i"  tl.e  unsf  i,K.,l   n  :,       .  "T   '"  ^''"  '•'""^^'^'""  ^''''  '"'•'•-'^^e 

=:;M!;::rt:!:;;;:r^ 

ii>i:en,iu.     In  son.c.  of  tlu'si-  c-a«os  tl„.  1.;  .f,  I  poniicuus 

.i<'f-tiv...ana  tl.  ...a.  ..on^;:;;'    J   ^     jr™  r^;;'--';;-  vc-y 

f'l'uh.^  atropine    hn     t  1  fc;'-^'"^^  i.KToas.,|.  an.l  the  .lan.l 

Klanduha.  la      ■^.         I^V        T^,  ''':  ^'^*---  ''"^t'-tion   .J  the 

i.>.ioai a..onnt i^ x';,:  i; v:;: ''  ;^''^-;' ■- --  ^i.  1,1.0. 

tl'---  wa.  con.plet,.  atn.pl.;  of    it  tn  n,l     "  "•'"''"'  "  '^^'""'  ^''"* 

exemption  of  the  nyloric       n  „  ''".'         '^  "'  ^''^'  ^""■•*'  '"-^an,  with  the 
n...seulari«  inucoi^  '      '     ^'"'"  "^'^  »^^^'^  ^'''^1<--'^  «!->  of  the 

abL:fi:;;oi'::xt:;;a;::r':'" '"' '-  ^''^  -^^  ^- '--  ^^--i^-i.  the 
tion  of  the  :  .h  sz;;"T''VT'v*'^ 

suHe,-e.liVon,a..      de.dl^  ,     r  '"     ^■'"'""'•"   '^'^''^i'^'^''   ""''  ''-^ 

a.ay  lead  to  n.o^  e  w'  U;.  "  t^  ^^"^  ''""  ""^  ""^""'"-  -""''tio-- 
do«tn,etion  of  tuhnt  T  X'l^^  ';;r;;"^  '"^'"""■-^-  --'^  -tensive 
there  was  no  hi.torv  of  •    -n  1    I  r  '  '"'''  '''''''"'''''^  ''>'  ^'^'"^^iek 

^uhn.te..iti.  of  thriri:^  sn;  ji:  -t:.^;^:  ^'--^^ve 

*  Loc.  cit,  2  T 

*  Brit.  Mod.  Journal,  ISTS^Ii  "  '  I  eei,trall,I«tt  f.  d.  ined.  Wissonsrhnftei,,  Bd  xx 

s  Archives  Geuerales,  January,  188fi. 


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Photo^aphic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


1. 


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'^■b'^"    i^^'*" 


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14 


HENRY,   OSLER,    ATROPHY    OF    STOMACH, 


certain  forms  of  gastritis  with  tills  disease  cannot  lie  regarded  as  in  any 
way  successful.  It  is  quite  possible,  however,  that  the  stute  of  the  small 
arteries  may  have  had  something  to  do  with  the  production  of  the 
atrophy.  We  have  learned  of  late  years  to  connect  indurative  p'  icesscs 
in  other  organs  with  arterio  -.clcrosis  and  the  endarteritis  of  the  nutritive 
vessels  of  the  mucosa  may  really  have  played  an  important  part  in 
inducing  the  wasting.  In  a  recent  review  of  this  subject,  Martin'  sug- 
gests that  certain  lesions  of  the  mucosa  may  be  due  to  these  end-arterial 
changes,  but  acknowledges  that,  with  regard  to  the  stomach,  the  facts 
are  as  yet  too  few  to  warrant  any  conclusions. 

To  the  other  anatomical  features  of  the  case  we  do  not  propose  to 
refer.  The  reader  will  doubtless  have  noted  the  identity  of  the  condi- 
tions with  those  in  ])ernici()us  anseiiiia,  even  to  the  hyperplasia  of  the 
bone  marrow  and  the  pigmentation  of  the  cells  in  the  organs.  One 
point,  however,  is  worthy  of  note,  viz.,  the  large  size  and  healthy  ap- 
pearance of  the  pancreas.  This  organ  varies  greatly  in  size,  but  we  re- 
gard it  as  certainly  hypertrophied  in  this  case,  and  we  may  see  here  pos- 
sibly a  compensatory  effo.t  to  supply  the  defects  in  gastric  digestion. 

A  careful  study  of  this  case  justifies,  we  believe,  the  conclusion  that  a 
primary  atrophy  of  the  mucous  membrane  of  the  stomach  does  occur; 
and  it  further  bears  out  the  original  suggestion  of  Flint,  confirmed  by 
Fenwick,  Nothnagel,  and  others,  that  certain  of  the  cases  of  progressive 
pernicious  ana;mia  depend  upon  profound  alterations  in  the  gastric 
tubules. 

For  the  sections  and  drawings  we  are  indebted  to  the  skill  of  Dr.  J. 
P.  Crozier  Griffith. 

1  Kcvue  de  M^decine,  January,  1886. 


' 


(1  aa  in  any 
i)f  the  small 
tlon  of  the 
ve  \v  1C0SSCS 
he  nutritive 
ant  part  in 
tiartin'  sug- 
ond-artcrial 
•h,  the  facts 

;  propose  to 
f  the  condi- 
)lasia  of  the 
rgans.     One 

healthy  aj)- 
?,  but  we  re- 
see  here  pos- 
igcstion. 
usion  that  a 

docs  occur; 
onfirnied  hy 
f  progressive 

the  gastric 


ill  of  Dr.  J. 


li.:  "I 


S'H 


li 


m  \ 


! 

1 

i 

1 

1 

1 : 

i 
1 

1 

j 

;    rt 

t' 

;   i 

^' 

•i  . 

1: 

^X  X 


CI  f^'  TiVRjGjjT  I.  liCTVKES. 


n- 


\ 


ON  CERTAIN  PKOBL HMS  IN  THK  PHYSIOLOGY 
OF  THI:  m.OOl)  COKPUSCLIiS. 


''delivered  In-foic  the 


geous, 


r 


»    >'% 


.  ir^! 


i 


ul 


RY 


\V1IJJAM  OSLER,  MD 

""■'""  ■""■""•«-'Valco,.lh.;e  OP  PHvsKiAN.    .  '      '' 

■■.NNbYL\ANIA,  PHILADKLI'HIA. 


'I       I 


KEPRIXTK.r)    I-KOM 

THE    iMEDICAL    NEWs 


April  3 


>  lo,  17.  1886. 


!  I 


!'.  * 


nU 


1  i 


WM.  J.  DORNAN,  I'RINl'ER, 
628-634  Filbert  St, 


i         V     :  I 


THE     BLOOD    I'LAQUK 


tre  so,„e<.f  the  mul  ,-    ,         "''  '^^nn.scles  .till  .en- 

->^'  P^'tholo,.    i  t  lu   h     ''■;'''"''°"^  '"  physiology 

nevertheless  sS'ni'r;     I'?"  '"°"""^'  ''->•  -^ 

Wood  haie  een  .  d  s  in  -  '"  '"  ""'P"-'-  "^  'he 
of  physiolo.vSr'^^e  ,''■';  """"^  "''^  ^^'^'^^  ^^-^^^ts 
sands  of  alMe  ob^e  S  h"  i;!"  '"  ^'^l'  ^'^  "^  ^■-- 
ently,  with  rude  and  nil  ^"''  l""?  and  ard- 

endeavorin,.  to  so  "e  tl  ^  id'  l/  '"=tr,„„ents,  vainlv 

bytheseco;;n.ono;-e;        S:,r-;:;t'V^-P-'-ied 
pIiysiolo-vhassomi,HH-,K     1     •  "" ''apartment  of 

pan.ntre;A,lt.     ^Z^S^^:^::;;^-^^^^- 
o  the  centre  of  certain  biolo^L      ';  "^  "^'^ '"^"'^"-'*^d 
here  seems  painfLdlv  slow    xJxZv'  '''^' P'"^^''-ess 
ton  Jones,  in  ,846  oft  em  ^hscovery  by  Wluir- 

corpuscle;,  .he  'ed  :;.:";,"'' 'r'^^.  '>'' "-  -"orless 
gratory  power,  and  he  d  "r  '  ^"'!"  ■^""  "^  their  mi- 
'^.nction'of  the  nu'r!^  "  r^,;;^^  h.ood-forn.in, 

P'^'tant  additions  to  <nn'  know  ed "e   ,     ^    ^'  ""'^^  ''"- 
The  activity  of  r,..,.,.-  ,     ,    ^"«^  ""  this  generation. 

-■^n,s  of  breaking  n  the  tavtT'  1'"^  "'^'•'^  ^''^ 
the  or,gin  of  thes'e  cor^^si^^  ,"';;:  Tv  "^'""•"^•'^ 
t-imly  less  dense  than  it  wa'  "''""''  '^  «>- 

A  peculi     ' 


peculiarity  of  these  p 


erennial  problems  is  tiiat 


cer- 


I  ('  If. 


.  >  f 


■i  •■ 

.    i 


i  ;■..-,  , 

1)  i 

1    1  ?    .' 

I. 

3 

A 

1- 

y 

,■;_■»- 

5 

I-       ,  il 


;    / 


-'!    >   1: 


'if 


^  OSI.KK, 

tain  phases  for  the  time  eni,Mge  the  attention  of  observ- 
ers, and  the  lal)orat()ry  activity  the  woild  oser  seems 
centred  \ipon  them,  with  the  result,  in  a  few  years,  of  an 
enormous  increase  in  the  Uterature.  After  the  (iiiestion 
has  been  thorou>;hly  fou^dit  out  and  quiet  is  resumed, 
we  are  tlianliful  if  only  an  outpost  has  been  gained  in 
the  struggle  and  we  are  a  stej)  nearer  to  the  citadel  of 
truth. 

As  regards  the  blood  corpuscles,  the  work  of  the  past 
few  years  has  been  largely  m  two  directions — toward 
the  determination  of  the  existence  or  non-existence  of  a 
third  corpuscle  in  the  blood,  and  in  the  study  of  the  his- 
tological processes  attending  degeneration  and  regene- 
ration of  the  corpuscles  in  disease,  and  upon  these 
subjects  I  shall  hope  to  engage  your  attention  during 
this  course. 

I  propose,  therefore,  in  the  first  lecture  to  consider  the 
much  debated  third  corpuscle,  or  hicmatoblast  of  Hayem , 
which,  so  far  as  1  know,  has  not  yet  received  systematic 
consideration  before  any  American  or  English  audience. 
In  the  second  I  shall  discuss  certain  histological  prob- 
lems connected  with  the  degeneration  and  regeneration 
of  the  blood  cori)Uscles;  and  in  the  third  1  shall  present 
a  statement  of  recent  views  on  the  relation  of  the  cor- 
puscles to  coagulation. 


THE  THIRD   CORPUSCLE    OK    HLOOl)    I'LAQUE. 


i  J:  i 


Definition.— ^^  colorless  protoplasmic  disk,  constant 
in  mammalian  blood,  measuring  from  1.5  to  3.5  micro- 
millimetres.  The  number  per  cubic  millimetre  in  the 
blood  of  a  healthy  adult  is  about  250,000,  but  their  num- 
ber varies  greatly  at  different  periods  of  life  and  with 
varying  conditions  of  health  and  disease.  The  ratio 
to  the  red  is  about  i  to  18  or  20.  They  are  delicate 
elements,  and,  like  the  red  corpuscles,  tend  on  the 
withdrawal  of  the  blood  to  adhere  to  one  another,  when 
they  form  the  irregular  granular  clumps  which  have 
long  been  known  as  Schultze's  granule  masses. 

,V,,,;;(.._It  will  be  necessary,  at  the  outset,  to  refer  to 
the  names  which  observers  have  given  to  this  corpuscle. 
Unfortunately  they  are  rather  numerous,  and  no  one  of 
them  entirely  satisfactory.     Donne,'  whose  description 


CAKTWKK;!,,.     r.KCTlKKS. 


observers,  Hatx^n  /,„',■  ^'"""^^  '^''  '"'"■<-'  ^^"^•^■"' 

writers  refer  to  this  p1..,,,  .  ,  "'"'^''•p'^f'-.  \  annus 
in  the  rese^JcS  k:^  ""^^  '"^  ^f ^^^ ^'":^-'^'.  while 
Laboratory   of    lohns   V   ,  f'  ^'•'"" 'he  Hioloyical 

Pl'r>/ue  is  Ise  1  an  h.  "'  "''  ,'''"i^--''-^ity,  the  tern, 
Manin.  To  the'  erms  M  w""f  "^'  ^■'^"^^'""  "^  '''"f- 
[Here  is  the  ti^  ,S:n  tu^^""  ''^•''"'^'^'^"' 
been  appHed  to  other  bocC"l,  ,'.'■"'  ""-'"''  '"'' 
With  the  elements  i„  que  S„  H  .  '  "°"'"'*^^  '"  ''" 
called  invisible  corpuscle      f  M  ^"'•'"'^■■' '"  ^be  so- 

the  nucleated  red  cor  ,I  r  ^"'■'"'  ''"'^  "^'^  '^tt^'r  to 
name  h.L„nob  ""'"-'"  "^  "'"  '^""^  '"^^"ow.  The 
theoreti  on  e;   i  ;J"°'^^  --"i-   with   it  certain 

bodies  whici:  ::rrm.;f n'lT '"  '""^^'""^  "^  "-- 

to  favor  the  name  ^hich  Hi  'l"'-     ^  ■'^'"  '"^"""1 

because  we  Se  In  leh     f'T'"  ''"'  '"^^'"P'^''-  P''>'-"y 
l^rofessor  fo.    a  se,  e     of  .b.  "^^^^^^^^  Turi,I 

awakened  the  liveTies    in  ■'T''''''^'   ^^''^''^h   ha. 

P--'lv  because    s     el  ttel '"      T  ^"^P"-'-' ='"'^ 

Jilood-plate.  the  En  dish  t     ''^^^""'^'•'"^^l  the  name. 

//<^M/..;/.isl     no.Sn     "''7"'^"'  "f  the  word  bint- 

^^"''  >"iKht  be  emn  o^.J'^','  '  f     ^''''  '""''^  convenient 
English  writer^.!  "  "'  '^^  ^^'"•-^^''^'^"  ^"^ 

barelyvisible  corpuLl      of  '    l'  '"   ''  ""'^..""  ^"'"  "^  "- 

f'e  boau.if,,!  photographs  i„      s  hnnf      m^?'     ''"'  ^'  «'"''y  "^ 

"-  with .  p..,i,,t  knl  V «::!;;";  !■';"'■  "r""'^'^  ^^^y- 

"'^"  "x^yare  separate  elomcms  T  '''°°^  P'^"«  °f  Hizzo.ero, 
'%.45)  as  resulting  tZZ\n^Z  ^''^""'''■^  ^^'"'^'^  '>'•■  figures 
fugitive  corpuscles  are  i^re- li.v  ,  7-  ""  "'  """  >'''""■""  ^^ 
Moreover,  tL  corpuscl.  w  hS  "': '^'^'""-'S'a'ed  I.loo<l.p|..,es. 
tl>an  the  blood-plates  ''  '^^"'"'-"^  ''''''  "'"^"'••"'y  'arger 

'--e  ;;::iJS:;:::?s^o;';:'"-^'  ''''^"  -  -^y  -^'■^"•«  ^or 

already  long  lis,     „,„  eover  a    ^  ''"°""^'  '°  ""'^  ^•"""''''-  '"  ""-' 

connection  with    ho!r.o,e;Tfeh  7",  T'  ''''=  ^"""  "^-'  '" 
rini  ,I,„i,..  „..  .,._:    :    .     °  ""^^'  ^  f*"  absolv->  r. .     ., 


5 


rial  duties 


on  their  behalf. 


led  n 


om  further  sponso- 


^'il 


.  I 

! 


.    j., 


I 
'  1 


1 

' 

i*      ,   ' 

'i ) 

i    '1       : 

■t 

/jl 

ril 
rl 

Hi 

G 


OSl.ICK, 


Mi-tlioih  of  Study. — Let  us  first  consider  llie  phuines 
in  l)lo()il  ex;iiniiic(l  in  the  >imi:i1  manner,  willuiul  the 
ad(lilit)n  of  any  reaj^a-nt ;  and  let  us  suppose  the  blood 
to  be  taken  from  a  case  of  consumption  or  cancer,  or 
from  a  newborn  animal,  .is  in  these  states  these  corpus- 
cles are  abundant.  We  then  find,  in  addition  to  the  red 
and  colorless  corpuscles,  many  ^jrayish-white  j;r''i">'l;i'' 
masses  of  various  sizes  and  shapes.  ICxamined  at  once, 
and  if  too  much  pressure  is  not  exercised  by  the  top- 
cover,  the  edf,'es  of  tiiese  masses  are  clearly  defined  and 
they  form  compact  aggregations.  With  a  power  of  500 
diameters,  the  composite  structure  is  well  seen  and  the 
granular  character  is  ])lainly  discernible  to  be  due  to 


I'l'i.  I. 


^ 


k:^ 


ct 


.''.^ 


a.  Aggregations  ot  pi.uiurs  111  human  blood,  forming  tlie  so- 
called  .^/-.f^/Zc  «Mi.>v?J  of  M. in  Scliiiltzc.  i.  DisinlogiMlion  of  tlie 
pla(nies,  with  fibrin  filaments  and  inucin-like  spheres  adhering  to 
the  mass.     c.   Isolated  plaques. 

the  agglutination  of  numerous  small  bodies  of  uniform 
size.  At  the  edges,  isolated  or  partially  free  corpuscles 
can  usually  be  noticed.  The  fibrin  filaments,  as  coagu- 
lation proceeds,  seem  to  radiate  from  the  masses  as 
centres.  This  remarkable  conglutination  of  the  plaques 
and  a  tendency  to  undergo  rapid  change  liave  retarded 
greatly  the  recognition  of  the  corpuscles  as  veritable 
elements  of  the  blood.  Observers  have,  as  a  rule,  seen 
in  them  nothing  more  than  a  granular  debris  of  no 
special  significance.  Nor  is  this  to  be  wondered  at,  as 
they  so  cjuickly  undergo  change  that  the  clusters,  in  the 
course  of  a  short  time,  really  present  the  appearance 


>  ll 


'  Al<T\\|tl,;||T     l,i:(    irUKS 

of  clisi„,ei;r„,i„„  ,„.>i„pl„„,  ||.-i„.  ,.  /,,.    The  ,i,,  .,„H 

aTaf:  n'iif ';;;r ;"  "■"•:  '»'^»'*  ^ "-  ''"-''■" 

o.i»lhc  at„reKal„.„s;  ,!,„  »,„.,||„  „„^.     „„„„„"'=' 

blood  of  the  adult  the  placuies  are  nnt  v.. 
Tnri  ^1         ^  r  h-xjiiucb  are  not  verv  numerous 

and  bO  do  not  form  vcrv  larrp  r„ii..,..;„         '.       "'^'^""^' 
rii,,;^,    1     1  '  ''"^e  collfctions.     In  some  in 

"'^'     \'  'J,-    I,    t  }.      I'OSSIJ  V   this    mnv    1i,.    .,.,  -1 

tion  th^  r„  I  "^  peculiar  mode  of  aerrreea- 

non.tne  red  in  se:   ■ ;  in<i  tu^  „i  •  "fah'^fe'i 

111  3c.  -  ,  tnu  tne  p  aaue  m  m-isspc     i  u 

"ever  seen  any  appearance  .'hid  wou  d      . .,  t ' h" 

It  was  a    consideration   of"  the    relative    si/e   nf  th. 

tinn.  V         ^  '         '"*^  blocdvesse  s  the   coller 

plain,,  a,  .h.  edge  of  t Tn^ssel:         "  '""  "  ""'"  " 


II 


OSI.KR, 


Si 


■i  i 


To  study  the  |)lai|ues  properly,  the  blood  must  l)e 
allowed  to  |)ass  directly  into  w  solution  which,  while 
preventing;  (■onj;litinati()n,  does  not  luatenally  alter 
their  form  or  iharactcrs.  ( )r  they  may  he,  perhaps,  more 
satisfactorily  observed  whiU-  still  within  the  blooilvessels. 

Various  solutions  have  been  employed  by  ditt'erent 
observers,  /.immerman,  whose  study  of  these  corpuscles 
was  really  very  complete,  allowed  the  blooil  to  flow 
directly  into  a  solution  of  a  neutral  salt  which  pre\  ented 
coagulation,  and  then  in  the  supernatant  lUiid  he  found 
small  colorless  cells  in  extrao-dinary  numbers.  I  have 
repeatedly  confirmed  this  observation  in  the  case  of 
horses'  blood,  when  demonstrating  the  common  experi- 
ment of  preventing  clotting,  by  letting  the  blood  How 
into  sodium  sulphate.  The  placpies  abound  in  the  clear 
serum,  and  if  the  solution  is  not  too  concentrated  they 
are  very  little  altered.  In  using  the  Inematocytometer 
((lowers),  the  sulphate  of  soda  with  which  the  blood  is 
mixed  acts  in  the  same  way,  although  in  the  counter  it  is 
more  common  to  find  the  pl.iqucs  aggregated  than  iso- 
lated, but  the  individual  plaques  are  unusually  di.stinct. 
More  suitable  solutions  for  histological  purposes  are  osmic 
acid  I  i)er  cent,,  the  tluidsof  Pacini,  modified  by  Ilayem, 
and  of  Hi/zozero.  I'.icini's  solution,  as  used  by  Ilayem, 
consists  of  sodium  chloride  i  part,  sodium  sulphate  5 
l)arts,  corrosive  sublimate  0.5  part,  in  200  of  distilled 
water.  Hizzozero  employs  the  ordinary  salt  solution,  ^{ 
per  cent.,  to  which  methyl-violet  has  been  added.  Afa- 
nassiew'"  recommends  strongly  the  use  of  salt  solution  to 
which  0.5  per  cent,  of  dried  pepsin  has  been  added,  and 
I  to  1000  of  methyl-violet,  and  a  small  amount  of  sub- 
limate or  carbolic  acid  to  prevent  decomposition.  I  find 
that  the  Pacini  lluid  and  osmic  acid  answer  every  pur- 
pose, and  in  them  the  placpics  undergo  very  little  change. 
The  examination  is  made  in  the  following  way  :  Upon 
the  thoroughly  cleansed  linger-i)ad  a  single  drop  of  the 
solution  is  placed,  and  with  a  sharp  needle,  or  pricker, 
the  skin  is  pierced  through  the  drop,  so  that  the  blood 
passes  at  once  into  the  fluid,  which  is  then  received 
upon  a  slide  and  covered.  The  withdrawal  of  the  cor- 
puscles into  the  solution  prevents  the  plaques  from 
aggregating,  and  they  remain  as  isolated  and  distinct 
elements.  The  amount  of  JDlood  allowed  to  How  into  the 
drop  must  not  be  large,  and  should  be  quickly  mixcii. 


'AUTUKKiliT    l.i:.    rCMKS,  ^ 

'.  ,2    I  pir  -cMit.,  winch  l,;i,  the  ailvaiit-i-e  (hit  hv 
'1-1  '  "'""^  '•'If  red  cells  are  supnt   in -i.- 

r';:;;.;;;r';;,"i;rs:,t'r:=trH:-';f 

iii//ozero  .s  paoer    inrl  in  »i,  ^'  "'" 

papei.and  in  tlie  recent  conununication  of 

I'li;.  2. 


PI, 


ques  Ml  circiikitiii. 


I'loo.i,  .)Mu-ntum  of  guinei.-piV 
i8,  I,  '83. 


Kberth,  full  directions  are   eiven    fr..-  fJ.„    .    1 
plaque  i„  ,l,e  circula.in.f  n",:,    "t,,''^=  "■'"■  "f ''" 


m  < 


1' 

; 

I    . 

i 

.      1 

•< 


,    '     .: 

^11* 

i 
( 

! 

1 
j    ■ 

lo 


itSI.I'.K, 


ft 


Siinderson's  Ha)idhook),  which  answers  every  purfjose 
ill  the  case  of  the  .ijuinea-piy;,  the  oinentiiin  of  which  is 
a  peculiarly  suitable  object.  In  the  rapidly  flowing  cur- 
rent no  plaques  are  distinguishable,  but  when  the  stream 
is  slow  they  can  be  seen  here  and  there  in  the  still 
layer  with  the  white  corpuscles,  while  if  the  current  be- 
comes very  feeble  they  tend  to  collect  at  the  periphery 
with  the  leucocytes.  In  a  small  venule,  where  the  stream 
is  slow,  and  only  a  few  corpuscles  passing,  the  best  op- 
portunity is  afforded  of  seeing  the  plaipies.  They  may 
be  well  studied  within  the  vessels  in  the  recently  killed 
animal,  o^  in  man,  in  portions  of  tumors,  etc.,  recently 
removed.  "I'hc  subcutaneous  tissues  of  the  newborn 
rat  atTord  perhaps  the  \'ery  best  situation  in  which  to 
study  the  plac[ues  while  within  the  vessels.  The  rat  is 
killed  with  a  snip  of  the  scissors  through  the  spine,  and 
then  portions  of  the  mucoid  connective  tissue  spread 
thin  u|ion  the  slip,  either  with  or  without  saline  solution. 
In  the  thin  transjiarent  x'essels,  the  jjlaques  are  very 
distinct,  anil  they  remain  unchanged  for  hours.  Per- 
haps chere  is  no  better  mode  of  studying  these  forms,  as 
the  thin  w;'"s  olfer  no  im|)edinicnt  to  the  \-iew,  and  the 
placjues  are  in  then-  natural  medium.  In  the  subcuta- 
neous tissue  of  man  I  have  had  several  opportunities  of 
examining  the  plaques  in  this  way,  and  Fig.  3  represents 


lii^iii 


%.\ 


I'lC. 


m 


o  a 


■  a  o 


■^    0  c  c    c 


^,     ^f' 


Plaques  in  srn.ill  artiTV  from  subcutaneous  tissue  of  scrotum  of 
man,  one  liour  after  removal.  Case  of  ele[)liaiitiasis.  20,  It,  '85. 
They  liad  collected  in  numbers  at  this  [jortiou  of  the  vessel. 


them  in  a  vessel  of  the  tissue  of  the  scrotmn  an  hour 
after  its  removal.  In  the  smaller  vessels  of  the  pia 
mater  they  may  also  be  seen. 

General  Characters  and  Sfnntiiie. — The  iilacpies  are 
minute  elements  circulating  in  the  plasma  with  the  other 


f  -AKTU-KIf;!!!-    r.RCTUKKS, 


ri 


n 


Isolated    phK,iu"s   in    nonnal    hloo.l.      Osmic  n,-i,l  , 
one-twelfth   jm.  ./Hss)       „    r,..i  "-'''""'•  'IlkI  i  per  cent.; 

The  plaque  is  colorless,  witi,  .i  luiifuim  grayish-white 
appearance,  u„„o,eneot,s  or  verv  iinelv  S  ,  r  ,nd 
presents  no  chnerent.ation  ,n  the  delicate    ro;!; pi;;;;,;^   ' 

The  s;zr  is  variable.  In  man  they  niav  be  said  to 
meastn-e  from  1.5  to  3.5  .nicromillLetr  s  !n  om 
abou  one.,..th  to  one-half  the  si.e  of  a  red  blood'  o" 
puscie.  I  he  majority  of  them  are  from  1.5  to  ^  r ,.  Qc 
cas.onally  a  plaqu.  n,ay  be  seen  measuring-  as'mnch  as 
.  m.crom,  lunetres.  but  tins  is  exceptional.  Whe  the^ 
a-  abundant,  remarkable  gradations  in  size  ma  £ 
.   easured    between    the    smallest    and    largest    fo  n  s 

2j--;-7heconsta,.cymsi.eofthe.edo;: 
Pi'^'-lt.  I  think  ,n  man,  when  very  abundant  the 
average  sue  .s  slightly  less  than  when  they  are  'ot  o 
numerous.  They  are  stated  to  bear  in  size  some  relv 
t.on  to  the  sue  of  the  red  corpuscle  of  the  anirn'r  ut 
we  need  a  uu.re  elaborate  series  of  measuren,e  Us  o 
detenn.ne  this.  In  the  white  rat  they  ue  s  ig  u ly 
smaller  than  in  man.  ^igntiy 

self  is  f "'"  1"^  'J^V""''""^  '''^'^l"^'  ^^^  '^'^^  '"  'l^e  ves. 
^N  ..  a  cncular  disk  w.th  smooth,  well-detined  margin 
W  en^lig  nly  tilted  it  has  naturally  an  ovoid  appe     -' 
ance,  anu  when  *^ccn  hi  nmf'iWi  ;-  .,  . 

J  ^.  lii  profile  lb  a.s  a  narrow   stra  flit 

rod  or  staff.     Whether  they  are  iiat  disks,  or  bi^o.Se! 


L.'.'  1 


h 

n.-: 

» 

j 

r 

) 

1 

: 

t 

< 

\!  ■ 

D 

;, 

.'i 

1 

I 

1  ', 

••    J 

»  i 

li  V 


1  M 

-■ 

1 

. .; 

t 


.4 


[3 


OSI.KR, 


as  the  red  corpuscles,  is  reall)-  nut  easy  to  ck'tennine.  I 
should  say  that  the  majority  do  not  show  a  bilateral 
depression,  but  forms  are  sometimes  seen  which  re- 
semble in  outline  very  closely  miniature  biconcave 
disks.  Alterations  in  form  (|uickly  occur  when  the  blood 
is  withdrawn  ;  but  the  natural  slia])e,  as  seen  in  the 
vessel,  and  also,  as  a  rule,  in  Pacini's  tUiid,  or  osmic 
acid,  is  as  here  stateii. 

The  phujue  consists  of  a  homogeneous,  smooth, 
structiu-eless  protoplasm  of  a  li},du  i,nMy  color.  In  the 
unaltered  condition  no  nucleus  can  be  seen,  but  in  the 
fluids  used  to  conserve  them  the  appearance  is  in  the 
form  of  a  collection  of  distinct  granules,  which  may 
look  like  a  nucleus.  This  will  sometimes,  in  dried 
])reparations,  slain  a  deeper  color  in  the  hiumatoxylon 
than  the  remainder  of  the  plaque,  and  it  is  regarded  by 
Hayem  as  a  nucleus. 

C/iaiix'i:f  I'!  iltr  /'/<??///(■.:.  — Outside  the  vessels  the 
plaipies  are  characterized  by  two  |)ccidiarities  which  have 
been  a  serious  hindr.mce  to  their  recognition  as  special 
elements  of  the  blood,  viz.,  the  rapidity  with  which  the 
protoplasm  alters  and  the  tendency  to  adhere  to  one  an- 
other and  to  any  substance  with  which  they  may  come 
in  contact.  Within  the  vessels,  however,  they  do  not 
seem  to  be  more  prone  to  rapid  decay  than  the  red  or 
white  corpuscles,  and  in  the  \-oung  rat,  kept  at  ordinary 


\./ 


r  '' 


^^     A      i     I 


(J 


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a  'J  J 
It 

a.  Changes  in  appnarnnce  of  the  plaque,  due  to  separation  of 
its  protoplasm  into  a  uarkcr  anil  clearer  portion,  fi  Alterations 
in  form  of  plaques  examined  in  blood  serum  and  watched  for 
three  hours. 

temperature,  I  have  seen  them  in  the  vessels  cpiite  dis- 
tinct and  clear  twenty-four  hours  after  death.  So  also 
I  have  found  them  unaltered  in  the  vessels  of  the  |)ia 
mater  in  man,  some  hoins  after  death  ;  and,  as  1  shall 
have  occasion  to  show  in  the  third  lecttire,  they  may  in 
masses  remain  apparently  unchanged  for  some  time. 
The  substance  composing  the  placjue  appears  homo- 


•^  I' 


CAUTWHKiHr    l.i:(TI'K|-S 

'  1 

Kjeneous  when  nrst  seen,  hnt  soon  a  chnnj^^e  occurs    ukI 

X£'Z  TT    '   f  ■''^■■'  '""^^   "■^•^'>-  -^-'    e 
|'"Uon  and  a  clearer  substance.     Usually  this    ,],rl:,- 

l'";t.on  ,s  peripheral,  hut  it  „,ay  he  cen       1  ,    t^' 

not  unhke  nucleus.     It  is  as  if  a  material  h  ul    e^^^^^^^^^^^^ 
-",  the   stron,a  or  bases  of  the   plaque,    us  'as   the 
.nu.^ob,,w.,   the   reel  co,-p.,scle  'm 
'"lluence  o(  rea,,^ents.     The  plaques  undergo  the  mos^ 
cunous  chan,a>s  in  shape,  to'the  study  of  t^^^i  h       de 
voted  much  tune  in  ,873.     Wuhin  the  vessels  tiev    re' 
c.rcu  ar,  but  when  at  res:  they  not  unfrec,uen, Iv  been;   e 
p-.ul  or   prolonged,  or  slightly  angular   ,n       ren   t    , 

•iKI    M\e  a   stellate   appearance  to  the   plaque       The 
;  -.'RCs  HHor.n  are  very  fully  described  Tn  irurec[n 

c    ced  by  chan.es  >n  the  external  con.litions  and  a  e  not 
.  n  -^1-jd  or  vital  in  character.     The  addition  o    se'    n 
'      '^1  '  "od  drop,  and  the  exan.ination  in  a  warm  staJ 

l^ven  u  thin  the  vessels  they  n.av  show  these  chancres 
-^^1  -"  the  course  of  a  few  hours  alter  in  a  re,,  tk tbTe 
"'anner  so  as  ,0  he  sca.cely  reco.mi.able  '""'"'^'^'^'^'^ 
Averyconunon  chan.L;e  ,s  the  separation  from  the 
pHue  . fa, nucn,.like(?)  material  inthe  form  ofapS 
rate  f.on,  „.     U  ,H.„  a:,,.eKate<l  in  masses,  as  in  a  slide 


■  I 


r 
) 
} 


k 


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I  ;j 


Alterations  in  the  pl.q,,.- while  within  the  bloodvessels  sk-  ,  h    , 
^'f'"'-  three  hours  on  the  warn,  s,a,,e,     6,  4    ^l, '      '"-'"' 

of  f>esh  blood,  th,s  process  can   be  readily  seen  at  th. 
"lai-m,  and  the  held  in  the  vicinity  n    J  ,  , 

-th  these  pale  ,loln,l..r  iKHhel   T      •  "  lit   dc:;;btr 
^n,thesepa,at,o.,ofso.nematerialf..;m;h;:SS 
o.ien  seen  attach-'d  tn  spermatozoa  in  urine. 


i 


t4 


OSI.K.R, 


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I 


IlL'ii 


\m 


In  marked  contrast  to  tlie  stability  of  the  plai|iies 
within  the  vessels  is  their  rapid  disintei^-ation  when 
withdrawn.  At  a  low  temperature  this  does  not  occur 
so  quickly,  and  of  this  Ilayem  took  advantage  in  his 
researches  ;  but  at  the  ordinary  temperature,  and  in  the 
examination  of  the  blood  without  any  rea),fent,  the 
platpies  unite  with  each  other  and  underL,fo  rapid  change 
— a  viscous  metamorphosis,  as  Kberth"  terms  it.  As  I 
shall  have  occasion  to  point  out,  this  is  associated  with 
the  separation  of  tibrin  which  seems  to  arise  lirst  about 
the  groups  of  placpies,  as  Ranvier  noted  in  1873,  and  he 
spoke  of  these  little  granidations — arraius  sarcoditjuc  of 
Vulpian — as  c-;ntres  of  coagulation. 

Action  of  Rrai!;tiits.—'^\\\'i  has  already  been  referred 
to  in  the  consideration  of  the  best  modes  of  examining 
and  preserving  the  plaques.  Water  reacts  upon  them 
as  upon  the  colorless  elements,  causing  a  swelling  of  the 
protoplasm  and  a  rapid  |)roduction  of  the  jiale  spheres 
already  described  1  )ilute  acid  and  saline  solutions  act  in 
the  same  way.  In  three-fourths  per  cent,  salt  solution, 
or  in  the  sodium  sulphate  solution  for  lilood  counting, 
they  retain  their  outlines  and  do  not  so  ra])idly  coalesce 
and  disintegrate.  Dilute  potash  solution  causes  speedy 
dissolution. 

The  aniline  dyes  stain  the  plaques  as  other  prcUoplas- 
mic  bodies,  and  Hiz/.ozero's  lluid  has  the  advantage  of 
tinting  them  and  making  them  more  distinct.  In  prepa- 
rations by  I'.hrlich's  method,  the  tint  of  the  central  por- 
tion of  the  plaques  may  be  deeper  than  the  periphery. 
Carmine  appears  to  have  no  effect.  For  i)ermanent 
preparations  the  dry  method  is  the  best,  and  they  may 
be  stained  with  hiematoxylon,  fuchsin,  Bismarck-brown, 
or  methyl-violet.  The  blood  in  osmic  acid  may  be 
kept  for  some  days  if  the  cover-glass  is  carefully  sur- 
rounded with  paraftine.  A  solution  of  corrosive  subli- 
mate I  :  1000  is  also  suit.ible  for  their  preservation. 
The  precise  chemical  composition  of  the  plaques  has 
not  been  determined,  but  from  the  similarity  in  most 
points  of  their  reacticm  and  behavior  with  dyes  to  the 
nuclei  of  cells,  we  may  supi)ose  their  composition  to  be 
of  a  similar  nature. 

Tlu-  Nunihcr. — The  numeration  of  the  plaipies  presents 
serious  difficulties,  on  account  of  their  extraordinary  ad- 
hesiveness and  the  nundjers  now  given  may  be  sub- 


M' 


I'AKIUKKiii  r    l,i:(  TI'KKS. 


'5 


ject  to  revision  when  better  nietiiods  are  devised       In 

n   the  u  b.c   milhnietre,    li,^r,i,.es   wliich   c-orrespond   to 
hose  of  Hayetn.      Full-blooded,  plethoric   i   Sa  ^ 
1-e  rarely  ntore  than   350.000  per  cubic   millinie    e 
Ihe  varuxfons  .n  the  san.e  ind.vidual  n,ay  be  co      d^  : 

n  1  me,  1.     A^e  has  an  important  influence-in  the  in- 

k'  '''"."•   ,''    "'^  newborn   of  all  the  mammals  I 

have  exatnmed  they  were  specially  abundant.     In     d 
vanced  a,.e  they  seem  more  nunirous,  parti  ulhf 
the  md.v.dual  is  weak  and  debilitated  "'^"'•'■'>'f 

Lnt.l  more  extensive  an.l  nu.re  reliable  counts  are 
announced,  we  may  say  that  the  placpies  in  J-  h 
number  between   300,000  and  300,000,  the  ratio  to 

cies  35  01  40  to  I.      I  he  nunierati(.n  of  the  i.huiues  is  1 
much   more  tedious  n>atter  and  requires  ti    morJ    a 
-ence   than    countin,   the    red    ancl   white     omsxles 

e.  ^  appa.atus.  as  the  mixtme  can  be  n,ore  thorou<dilv 
and  qtnckly  nK.de.     The  l,lood  is  ,ot  from  a  d  ep     unc 
t".X'  and  aspuated   into  ,hc   tube  of  the   PoS  mKer 
and     e,.  the  Pacini's  fluu.  or  osm.c  acid, simZl'X 
t^^s^cJT'r    "   "'"   '''  '"^'"'Ithat.  with  the 
Poc?ss  m^/r     '  '"'"":  '''""^  '""   '"^^^^^her  and  the 
pioccss  must  be  repeate.l.      It  is  essential,  too    in   th-^ 
firs   aspn-atton  of  the  blood,  to  re.ch  the  li'ne  at     n  e  ■ 
f    he  blood  column  ^ces  beyond,  it  n.ust  be  diseased 
and  a  fresh  attempt  made,  as  thetin.e  lost  in  accur  itcl 
acljustu,,  the  column  wo.dd  be  sufhcent  to     lit,  ' 
plaques  to  coalesce.  "^^ 

77u-  Phu/ues  in   Dh,a,,:--\n  health  the   plaques    ire 
ela Uvely  scanty,  and  they  ag;,re«ate  into 'su.-     sm'   I 

m  "r  ''TT'  ""'^  ^'^^>-  •'"  "^'  necessarily  exci  1  e 
a  tem.on  01  the  student,  but  every  constant  obser  er  of 
the  blood  m  states  of  disease  must  have  marvelled  a'  tin 
and  agam  at  the  extraordinary  number  and  !  e  of^l  e 
granule  .nasses  met  with  m  certain  cases.  L  d " nv  \ 
by  the.r  constancy  and  pecuhar  character,  writers  hive 
regarded  then,  as  specific  and  dlstincvc  el  nents  In 
certain  aflecfons  (leukaemia,  phthisis).     K.on  T  ab 


* 


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t 

i    1 

I 

I:;, 

I' 

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0 

,  1 

1 

» 

;, 


ii, 


i6 


OSl.HR, 


and  comprehensive  paper  of  Riess  to  the  more  recent 
one  of  Afanassiew,  tliore  have  been  very  many  observa- 
tions on  the  freciuencx'  and  sii^niticance  of  tiiese  bodies 
in  disease,  Ijut  we  still  lack  careful  and  i)ainstaking 
enumerations  in  the  various  acute  and  chronic  tliseases. 
A  rouLjh  estimate  of  their  increase  or  diminution  may  be 
made  by  any  one  well  accustomed  to  their  observation, 
l)ut  for  scientific  accuracy  the  hicmatocytometer  must  be 
used,  and  means  must  be  devised  to  overcome  the 
present  serious  source  of  error. 

^ly  own  observations  have  been  very  numerous,  and 
I  have  for  years  been  in  the  habit  of  noting'  the  paucity 
or  abundance  of  these  elements.  In  the  absence,  how- 
ever, of  systematic  and  reliable  counts  the  notes  are  not 
worth  much.    The  ^'eneral  results  I  may  state  as  follows  : 

1.  The  plaques  are  increased  in  all  chronic  wasting 
maladies — cachexia- — with  or  without  fever. 

This  is  very  evident  by  examinini,^  in  rotation  the 
various  patients  in  a  hospital  ward.  The  debilitated 
individuals,  the  subjects  of  phthisis,  cancer,  or  other 
chronic  wasting  diseases,  present  a  marked  increase.  In 
phthisis  the  number  per  cubic  millimetre  may  reach 
500,000  or  more,  and  the  ratio  of  the  plac|ues  to  the  red 
may  rise  as  high  as  i  to  5. 

2.  In  acute  sthenic  fevers  the  plaipies  are  not  in- 
creased in  the  early  stages,  but  as  the  disease  advances, 
and  the  patient  l)econies  weaker  and  more  debilitated, 
the  increase  is  usually  marked.  This  is  well  seen  in 
typhoid  fever,  in  which  the  number  of  placpies  during 
the  first  week  may  not  rise  above  normal,  while  in  the 
third  and  fourth  week  there  is  usually  a  notable  in- 
crease. 

3.  In  the  so-called  blood  diseases  the  number  of  the 
platpies  is  variable.  Many  observers  have  remarked 
the  great  numbers  in  certain  cases  of  leukicmia,  but  in 
others  the  increase  is  not  apparent.  So,  also,  in  lymph- 
atic aniemia.  fn  some  cases  of  Hodgkin's  disease  I 
have  seen  the  placpies  in  extraordinary  numbers.  In 
profound  an;emia  the  plac[ues  may  be  very  scanty.  1 
have  long  noted,  in  cases  of  pernicious  antcmia,  that 
the  clusters  of  placpies  may  be  almost  absent,  or  much 
more  scanty  than  in  health. 

Distribution  of  the  Plaqiii's  in  Animals. — So  far  as  our 
present  knowledge  goes,  the  plaques  are  constant  con- 


!■  -ivr 


\-  Hi 


'  AKIUHIGIIT    I.KCTrKHS.  ,7 

slituents    of  the  blood  in  mammals  and   with    fh. 
cept.on  of  .li,.ht  variations  in  si.e   tie     ene       <^^?  '" 

..rtheir'p.-::;;;:.:";;^;;::!'--:;!;:;;,--;^-^ 

^-.nea-p,,,  .-abbit,  .hcep.  ox.  honse   ,^1    ''    "''  '"°'"^' 
nul^ld      .-"""■  '"   ^''^  "-I--''.  -^'1  here  they  are 

logically  an^ii  •:rS1;;;z;:^^:'';;;^ '^p^fo- 

;;;™als,  and  .h,ch  behaves  Le',t.i;:„Xt:,;^ 

accS;b7ii"':;';i:^!f;;;r'";"  '"-^  '^^"  ^'-" '° 

"derates  no  loss    1    ,"  '''''"'''  ''^"''  '^'^'"P  enu- 

the  most  pr  V  le  t  de?""  ,"";""/  ^''"^^-  ''-^'''1- 
physicians'  Lt-Utl  '7",'"'""'^  •'^"'""^^  '^'i"'^'^' 

-Hi  ciegenera.o;  o  LT;'"'  '"'"  '^^^^  ''-"te.ration 
the  leucoc^,es  Tl"i  J  ?"'  ""P^-^'e^.  especiallv 
in-e,tdar  clumps  l?;,",^';'rV'"-^^'"-'.  for  the 

ordinarvway  look  ven  lit  '/       -^''''"'"^'^  '"  '^'' 

Plasmic'deb,  s     iLZl  ^   '  '"''""''■  '"^-P'oto- 

ciisinte,.^ati^■in    1  e    '  lo  I  "  "°  '"^'^  ^'"'^^^'^^  "^  '^P'^'^ 

"uarkablv  strblTelomet  , "''■'"''''''  "'^''^'^  ''^'■^  ■'^- 

ciecompo^itionet ":;;;::, '""" '"  :'"'^  "^'■'^'^  -^1 

structures  sin,i!ar  to  the  rn  '"7  7"'^"  °"''  P''«^"<^e 
that  the  form  on  °f  the  T  ''^  "^ /''^^^'es.  The  fact 
of  placues  l:^"!^"^^""'''-''^^''^'-^  ^he  groups 
the  blood  direc.h  int  o.  ;  "   ^'%P''''''''<^   '^v  drawing 

""-".  i"  whi  1  he  n  ts' "  r^'r-'^"^'  '"••  '"-'"•  ^ 
be  sufficient  to  con  -in  e  '"''  '"''""">''  ^'^""'^ 

does  not,  the  stud    c    th.     ?  '""*'  .'^^P''^^'"  =  "^"t  i^  it 
-ill  satiJf^,  I   U  ink      l' 'Jfr"'r^  "^  ^'"  "^^^■'^"■•"  ^^^       ^ 
anceandiarge      l^f   iJ       '  "'"'-"■'^^"-     '^''^^  '-^bund- 

d.ope.ami,Sn:;u:;ts::af'^;;n:^'r 
ti-ewithZ^^  X'v;rv^'"''"'^ 

--•  -ith  those  in  . le  o^'.i;  'n  V^"'  "'  "'^  ^'™"P^' 
elusion  irresistible    Int'r  ,     r''''  '''''^''  '^'^  ^""- 

.'^teindepende.!:.;?^;;;,:!::^^::;^--^-. 
-.en.at.onort^-:i'r;;:s;'^.^^---! 


■  r 


.-i 


r 

i 

t   I 

I'    I 

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1  i- 


f 


1 1 


!! 


I» 


OSLEK, 


sider  the  views  thai  the  i)la(Hies  lepiesfiit  fibrin  par- 
ticles, or  are  tlejiositions  of  i,'liil)iiUn. 

A  majority  of  observers  rej^ard  the  plaques  as  inde- 
pendent elements  in  the  blood,  others  a^ree  with  Hayeni 
that  they  are  yoiin^  red  corpuscles — haematoblasts — 
and  a  further  discussion  of  this  point  will  be  best  con- 
sidered in  the  next  lecture,  when  1  ^peak  of  the  regener- 
ation of  the  corpuscles. 

Historical. — I  do  not  propose  to  enter  into  the  literature 
of  the  blood  placpie.  This  has  already  been  done  very 
fully  by  several  (lernian  ohser\  ers,  and  (piite  recently 
by  Kemp,  whose  pajicr  in  the  "  Studies  from  the  Biolo- 
gical Laboratory  of  Johns  (ioiikins  University,"  will  be 
readily  accessible  o  all  American  and  iji};lish  students. 
In  my  original  paper  1  have  also  <,riven  |)retty  fully  the 
older  references.  We  may  conveniently  divide  the 
work  which  has  been  done  in  this  department  into  three 
periods  The  first  embraces  the  time  prior  to  the  ])ubli- 
cation  of  Hayem's  researches  in  1877.  The  masses  had 
been  observed  frecpiently,  and  the  corpuscles  had  been 
studied,  notably  by  Donne,  Zimmerman,  and  Max 
Schultze.  In  1S74  1  demonstrated  the  corpuscular 
nature  of  the  granule  masses,  and  showed  that  the 
bodies  of  which  they  were  composed  "were  present  as 
separate  elements  in  the  vessels,  and  showed  no  ten- 
dency to  adhere  toj,rethcr."  In  1873  Ranvier'-'  called 
attention  to  their  possible  association  with  tibrin  fcnana- 
tion.  Riess  and  others  had  called  attention  to  their  in- 
crease in  disease.  The  second  period  dates  from  the 
publication  by  Hayem,  in  1877-78,  of  his  researches, 
and  to  him  really  beloin,'s  the  credit  of  establishing 
the  histological  jjosition  of  these  corpuscles  as  con- 
stant blood  elements.  It  is  curious  that  his  careful  ob- 
servations met  with  very  slight  recognition  among 
physiologists.  The  interest  in  the  (piestion  had  almost 
died  out  when,  in  1882,  Hiz/ozero,  ot  Tiirin,  published 
an  exhaustive  article  in  X'irchow's  A>ihii<  upon  the 
Blutplattcltc}i,  and  their  relation  to  fibrin  formation. 
From  this  we  date  the  third  period,  during  which  there 
have  been  already  published  eighteen  or  twenty  essays, 
chiefly  in  Germany,  and  the  most  intense  interest  seems 
to  have  been  aroused  in  the  subject.  The  weight  of 
histological  evidence  is  strongly  in  favor  of  the  views 
which  I  have  here  laid  before  you,  but  there  still  re- 


'  AKlWKU.ilT    1-KCTUKKS. 


ti-'of  t4r*,  ;'7r''',  1  ">r""  •-  "■  •'-  f"."-- 


I!lli[,|()(;|<  U'II\, 


,8;3.'^"""'"    Co,„p,.   ,.enc,.  .,e    I'Acad.  des   Sciences. 


J.  ^immern.an:   \'irclunv's  Archiv,  Bd    xviii 
3-  Sclniltzc:  Anhiv  f  nnl-,.    a      .  ' 

+•  |a)cm.  Arrhiv  del-hysiol.,  ,878-70 
5-  Hi/«,zer(,;  W.  Low's  Archiv.  IJd.  xc! 


j.'?n'H:;!;:,,::'S:,Sr!-.r-'"--'^-'o™ 


«•  O.ler:   IVoceedin.us  of  the  Roval  Societv    ,^^, 
9^R:.nv,e,-:(;a..Med.deI>a,is;,873         ■       ''^• 


»'  I 


^11 


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■;? 

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1 

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I   ' 


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If 


LECTURE  II. 

DKCKNERATION  AND  RKGHNKRATION 
OF  THP:  CORl'USCLES. 


<l»ss  10  the  Indivklual  exiemal  medium 

or  obvious  phenomena.  The  cornnJl«c  ^''"^'"^ 
remarkable  sameness,  and  \^  c\Zt  Z^'''''''''.  "^ 
readiness  the  old  elements  readv  to    ,i      or  T  ""' 

elements  and  are  removed  from   it  before  th^v 
changed  as  to  be  no  longer  recogniiblf "  ''''  '"^  ^° 

I  hat  the  red  corpuscles  in  henUh  are  rr^nst-ntl    ^ 
generatmg  and  as  constantly  being  re^^odled:? unl" 


;l   I     i' 


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; 


ta 


osi.r.K, 


versally  acknowled^jt'il,  iiimij;!!  ilie  fads  niion  \vlu(  li 
this  Ijiliuf  is  ha^^cil  iire  not  very  iiiiincrmi>.  'I'lKie  is 
evidcmc  that  tlic  iciloriii;^  mattcis  u(  tiie  hiic  and  of 
urine  are  (lfri\i'(l  t'lum  tlu-  li.i  in')L;lol)in,  anil  to  siippb 
their  daily  aniount  many  CDrpurii  Ifs  must  hf  di'stroyfd, 
and  to  replace  wliii  h  new  ones  ninst  be  foimeil.  'I'lie 
variations  in  number  at  dilTereni  times  and  uniler  dif- 
ferent conditions,  indicate  that  waste  and  repair  arc 
ceaseless  processes.  Moreover,  there  is  the  direct  evi- 
dence in  the  present  e  of  dei;eneratin^  ''ed  corpuscles 
in  certain  or^jans,  spleen  and  bone  marrow.  Our  very 
imperfect  kno\vledj,'e  of  the  details  of  de}.jeneration  and 
re;,'encration  of  the  corpuscles  in  health  has  been  sup- 
plemented to  some  t.'xteiit  by  exjierimcnt  and  Dy  the 
study  of  th"  blood  in  disease,  and  I  jjropose  in  this  lec- 
ture to  touch  upon  the  salient  features  of  these  proces- 
ses so  far  as  we  at  present  untlerstanil  them,  As  it  is 
difficult  to  separate  the  two  conditions,  whi(  h  in  many 
instances  coexist,  1  shall  lirst  take  up  the  consideration 
of  the  state  of  the  (  nrpus(  les  in  an.emia,  as  induced 
either  by  increased  destiuctiou  or  loss  of  the  corpuscles, 
or  as  it  results  from  ncanty  production.  The  loss  may 
be  sudden,  as  from  hcm()rrha;;e  or  acute  poiMins,  or  be 
a  slow  gradual  process,  as  in  fever  and  chronic  poison- 
ing. Aniumia  from  imperfect  production  of  cells  may 
result  from  primary  clianj^es  in  the  cyto^^enic  tissues, 
or  be  a  secondary  effect  of  imi)erfi'ct  luiirilion,  but  in 
either  case  the  reduction  in  the  number  of  .he  red  cor- 
puscles is  !i\-  far  the  most  impor'aiit  <  ''  t  "  anil  upo  . 
this  the  symptoms  mainly  ilei)e"i'. 

In  health  the  red  corpuscles  present  a  remarkable 
uniformity  in  size,  or  perhaps  it  is  more  correct  to  say 
that  tue  variations  which  occur  are  within  very  narrow 
limits.  The  large  ])roportion  of  the  corpuscles  have  a 
diameter  of  7.5  //,  but  there  are  a  few  to  be  found  which 
measure  a  micromillimctre  less  or  more,  6.5  or  8.5//. 
These  slightly  smaller  and  slightly  larger  forms  are  not 
r  -.mierous  in  normal  blood,  not  so  numerous,  1  think, 
;-.s  Hayem's '  researches  would  indicate,  for  he  places  the 
medium-sized  at  75  per  cent.,  the  sntaller  forms  at  12 
per  cent.,  and  the  larger  at   12  per  cent.     Gram,'' who 


'   I.econs  sur  les  mollifications  du  Sang.  1882. 
^   Foilscliriue  dor  Mcdecin,  1334. 


•■AKIUKIi.llr    I.Ki    ||Il<|.;s.  ,, 

1.-  ....Hi.  ,  ,nnnbcrof,..rcful  ob.erva.ion.  on  ,|.,. 
7.5  /(7.«  //)  ln,t  the  ,,cr,cnta;;c  of  ror,,us<lcs  „f  l,,s 
vu  ...N.      Ill   the    lu^ulmni.  and    f„i    ...nie   time  uhov 

"f"^  from   10.3  „  to  5.3  „.     ,):„;  „|    (he  most  striking 
al  eration.  of  the  red  corpuscles   in   .  ertai,.   ch  ea  "d 

oM       •'  ^'  "-y"^"  "^  "'^'  s.^cM.f  nulivuiual  corpuscles 

o  a  decree  ulnch  ,s  truly  remarkable.     la.tea.    of  an 

extreme  vanatH.n  of.,,  a.  i„  h.Uth.  the  ra,i,'e  bette" 

u  ed  from  .  ■  '""'  '""V",^'  ""■|n..cles  may  be  measi 
as  mu  .  "  ^■'  '"  '■''"'^  ^^""l'^'"<'>'s  'ells  may  be 
?or  ;r       ■  "  "■■  '■■'^■"   '-^"-     '^'^  ">"-■  '-^hnotmal 

J/Zfrnj/...  occur  n.an.ally  ,n  the  blood  of  the  embrvo 

f-  K.  to,  /M  an.l  newborn,  but  are  rareiv  to  be  seen    n 

a  healthy   adult.     I.whsease  they   are  \„ostabu,ulant 


I 


1 


■i  ■■  ■  > 


r: 


Ou.lm.s  of  r..,l  co,va,cl..s  „,  ,>  case  of  profound  an:.n,i ,      ,   i 
Very    irregular   forms -poikilocytes       a    V  t,.      *=    ,    -V"-     3.3- 

i.J  an.cmia,    whether  from    hen.orrlu.^e  or  as  a  result 

f  chanj^estn   the  cy...^enu-  „r,ans,  or  secnulan 
di^ease  of  important    .  „cera.     When   the  attention  o 
observers   was   lust    dnccted    to   these   bodils    t   V" 
S^!^l^:^^-"^"^^-"^^'-^"--m;;rMn 


»in  forrns  of 


aiii.L-mia,  but  we  ki 


ow  now  that  they 


i 

f  1.  ;': 

-■'f    i  "  ■ 

R) 

. 

24 


OSI.ER, 


i  !:! 


I  I. 


occur— in  variable  numbers,  it  is  true — in  all  forms,  in 
chlorosis,  splenic  auicmia,  jjernicious  an;i;mia,  leu- 
kannia,  Hodgkiii's  disease,  and  in  the  aniemia  of 
cancer,  phthisis,  and  otlier  chronic  affections.  I  must 
say,  however,  that  so  far  as  my  ])ersonal  experience 
jjoes  I  have  not  met  with  ihcm  so  uniformly  or  so 
abundantly  in  any  condition  as  in  those  cases  which  we 
designate  by  Hiermer's  name  of  progressive  pernicious 
aniemia.  In  what  may  be  called  the  ])rimar\  an;emias 
they  are  almost  invariably  to  be  found,  while  in  the 
secondary  form  they  are  variable  and  may  be  absent. 
There  is  unfortunately  a  difference  of  opinion  as  to  the 
nature  and  origin  of  the  microcytes,  some  regarding  them 
as  disintegrated  remnants  of  corpuscles,  others  as  young 
forms  in  process  of  development.  Possibly  both  views 
may  be  correct.  The  small,  spherical  bodies  of  a  deep 
red  color,  1.5-2.5  /;  in  diameter,  should,  perhaps,  be 
distinguished  from  the  forms  slightly  larger,  more  dis- 
tinctly discoid,  and  less  deeply  tinted.  That  they  may 
result  from  changes  in  the  ordinary  red  corpuscles  is,  I 
think,  certain.  I  have  fre(|uently  noticed  that  they  ap- 
peared to  increase  in  a  slitle  kept  for  observation. 
They  resemble,  too,  ])articularly  the  small  deep  red 
ones,  the  fragments  into  which  the  red  cells  disintegrate 
under  the  influence  of  the  imluction  stream  and  of 
various  solutions.    In  a  freshly  prcparetl  slide  of  an;umic 

.    •  V\r..   2. 


:^j 


^y^ 


Ol\^ 


tkiMii  I 


Extreme  poikilocylosis  in  blood  iVom  aiKcinic  patient,  ex- 
amined in  Pacini's  tliiid.  It  illustrates  also  a  possible  mode  of 
origin  ol  tlie  iiiieiocyles- 

blood  firm  pressure  on  the  top  cover  will  sometimes  be 
sufficient  to  produce  a  large  number  of  microcytes 
which  result  from  the  destruction  of  the  red  corpus- 
cles by  pressure.  They  may,  indeed,  be  observed 
in   process  of  formation    as  shown  at  Figs.  2  and  3. 


\m 


CAKT\VKI(;HT    I.KCTl'KKS. 


n 


Normal   blood    ,n    Pacini's   fluid   does   not    often  show 
special  chan,^res  ,n    the  form  of  the  corpuscles,  l,ut  the 

con.uscies,n.  cases  of  profound  amumi;,  ma;  bi;': 
m    t  ve  >•  M-reguiar  ,n   outline  and  deeply   fissured  as 

.n  the  field  as  microcytes.     In  the  bone  marrow,  tio    I 
have  often  noted  a  somewhat  similar  process  (Ki>r.  3), 

Tit;.  ^. 


M' 


■  * 

■i 


1 1. 


&>^ 


Origin  of  microcytes   from    red  cor 
.'uid  fission 


iipuscles   l)y  process  of  Ijudding 
.Specimen  from  red  marrow. 

^^'Zir-n!  '"""'"^'  •^'"'  '^--^  --^>'  -"all  forms 
3    .  ?°  niicrocytes  are  not  always  to  be  re- 

S  In'brr"'  °'  P"^^-"-'-^-"  c'^-^^e,  tiLy  n.  •  be 
seen  m  blood  exammed  with  the  irreatest  possible 
ap.d.ty  after  removal.  Whether  the  s li,l  ly'  K^^' 
form  of  ,n,crocytes  from  3.5  to  5  ,,  and  .hid.  a  re  X 
les  deeply  tmted,  arise  in  the  same  wav  is  still  an  un 

sm!Zr7'^''^'T'  '"'''""  ^"'■''^'^^'^^'  '^^«  '-^"ention  than  the 

They  L.y  reach  a;  t;:o,^,^.;.;^^r;^ 'r;::i 

even  ,5  ,.  They  are  very  constant  elem  n'ts  in 
-es  c.f  pe..,c,ous  an.mia,  and  also  occ.!;-"  Jhl" 
"osisand  leuk;emia.  (}ram'  has  made  the  interestin^r 
conservation,  which  I  have  been  able  to  confirm  t"xf 
these  forms  occur  in  numbers  in  cases  of  icter  He 
|iUo  states  that  ordinary  red  corpuscles  placed  in 
.aenc  serum  (of  ascites  in  cirrhosis)  seem  to  hatie 

neS^;he'\.f^-  '^  '"^^'  ''''  '"  '--'  ■-■-"- 
nection  the  peculiar  lemon  or  subicteroid  tint  of  the 

sloTMTMnany  cases  of  pernicious  an..mia,  and  possibly 
'  '''o'tschritte  der  Medicin,  Rd.  ii. 


I   ' 

■i,    » 

I    1 


■jLt 


I     I 


i    i 


m 
m 


Ji, 


, 


■ 


1^1  i  I 


[         \4 


i). 
} 


it 


P 


OSI.KK, 


there 


,'xist  in  the  l)ln(>cl-sernin  smne  clement — the 


product  of  destruction  in 


the  h.tiiu 


.'hich 


niav 


ict  upon 


the  red  cells   and  cause  them  to  assume  a 


more  ilattened  form.  These  mei^^alocytes  often  show 
the  most  eccentric  chan,i,'es  in  outline,  to  which  I  shall 
shortly  refer.  When  I  speak  of  the  development  of 
the  corpuscles,  1  shall  return  a;.,Mni  to  tiicse  forms. 

In  the  normal  red  corpuscles  re.Ljularity  in  outline  is 
not  less  constant  than  unitormity  in  si/.e,  Init  in  the 
blood  of  the  various  an.cniias  we  now  recognize  the 
loss  of  this  character  as  a  very  distinctive  feature. 
Here,  also,  many  of  us  cncd  in  sujjposing  this  condi- 
tion to  lie  ijcculiar  to  jjcrnicious  amemia,  the  disease  in 
which  these  irrej^ular  forms  were  first  accurately  de- 
scribed. (Hiincke  called  them  /ni/Vc/Ahj/tS,  a  term 
which  has  been  very  gener.dly  adopted.  At  Fijjs.  i 
and  2  this  condition  is  rejjresented.  The  corpuscles 
may  present  the  most  remarkable  shapes,  ovoid,  elon- 
gated, pryramidal,  balloon-shapes,  with  indented  edges, 
or  rods,  either  straight  or  bent  at  right  angles.  Many  of 
these  bizarre  forms  are  scaicely  recognizable  at  hrst  as 
red  corpuscles.  1  still  hold  that  we  meet  with  these  forms 
in  a  more  extreme  degree  in  cases  of  pernicious  anae- 
mia than  in  any  other  disease,  but  they  occur  also  in 
the  aniumia  of  phthisis,  cancer,  and  inanition.  This  is 
a  physical  change  depending  jjrobably  upon  alterations 
in  the  blood  serum.  It  is  not  induced  in  the  healthy 
corpuscles  by  dilution  of  the  scrum  or  slight  grades  of 
concentration  or  by  any  of  the  reagents  which  tend  to 
produce  crenation.  In  Pacini's  lluid  the  corpuscles  of 
anitmic  blood  may  sometimes  he  observed  to  become 
much  more  irregular  in  form  (Fig.  2}. 

Peni-n/i>i^f  of  l[a'mo;j;lobin. — We  know  as  yet  little 
or  nothing  of  the  processes  associated  with  the  produc- 
tion of  the  coloring  matter  of  the  corpuscles.  In  a 
state  of  health  the  percentage  of  hiumoglobin  in  each 
cell  is  tolerably  definite,  v.irying  within  very  slight 
limits.  In  diseased  conditions  we  have  learned  to  recog- 
nize two  remarkable  changes  in  the  relation  of  the 
coloring  matter  of  the  corpuscles.  t3ne  is  the  observa- 
tion made  some  years  ago  by  Duncan  (1867)  that  the 
htemoglobin  in  chlorosis  was  reduced  out  of  proportion 
to  the  reduction  of  the  corpuscles,  so  that  the  individual 
worth  of  each  red  corpuscle  in  coloring  matter  might 


i        A; 


«'  ! 


(  AKT\VI<lf;nr    I.K(  Tl'KF.S.  37 

be  very  ^rreatly  lowered.     The  true  an;eniia  miirhl    be 
"hh:1>  K'>;e;Uer  than    the   lu.ml.er  of  red  corpuscles  per 
cul.ic  nnlhmctre  mi^ht  indicate.    Subsequent  researches 
lave  fully   borne   out  this   fact,  for  which,  however  we 
Have  as  yet  no  suitable  explanation.     The  pallor  of  the 
.:orpuscles  may  even  be  reco-ni/ed  with  the  microscope. 
In  ordinary  anamiia  from   hemorrha^re  or  or-anic  dis- 
ease, the  avera-e  worth  in  ha'm(.,;lobin  of  each  corpus- 
cle usually   remains  unaltered  and   the   percenta-e  of 
coloring  matter  .-orresponds  closely  with  the  pcrcenta-e 
of  the  corpuscles,    but   in   certain   cases  of  pernicious 
anannui  the  mlerestmg  fact  has  been  ascertained  thnt 
the  percentage  of  h;emo,^riobin  in  each  corpuscle  is  in- 
creased, and  the  ana-mia  in  realitv  may  not  be  so  yreat 
as  the  reduction  n,  the  number  of  red  corpuscles  would 
appear  to  indicate.     The  individual  worth  of  each  cor- 
puscle m  lKi-m<,Kloi)in  may  be  actuallv  doubled  and  -he 
hei-htened  color  be  evident  on  microscopic  examina- 
tion.     Ihese  two  facts,  intensely   interesting  and   sug- 
gestive, may  be  said  to  comprise  our  knowled.re  of  the 
changes  m  h;v..mo,>,^lobin  percenta^^e  in  the  corpuscles  in 
disease   and  they  serve  as  a  back.,Mound  aj^^ainst  which 
to  display  our  i-norance  of  this  most  essential    feature 
in  niematogenesis. 

NucL-atci  R,d  Corf„nclc,.-\n  anaemic  states  there 
may  be  present  in  blood,  nucleated  red  corpuscles  such 
as  normally  oc(  ur  in  the  blood  of  the  embryo,  and  such 
as  are  present  ii.  the  red  marrow  of  the  bones,  I  have 
not  met  With  these  elements  so  frecpicntly  as  the  state- 
ments of  certain   observers  (Khrlich)  would  lead  us  to 


;  ? 


NucU-atcl  n-.I  l.loo<l-oor|,uscles  from  blood  in  cast-  of  leuka-mia. 

suppose  Certainly  they  do  n<,t  occur  in  all  cases  of 
profound  ana>mia.  1  have  met  with  them  in  leukaemia 
in  larger  numbers  than  in  any  other  state.  (Fi-  ,) 
rhey   present  characters  identical  with  the  nucleated 


J 


1  V  ! 


.1  ■     !!:.}' 


vm 


/ 


/ 


if 'in 

■ 

ill 

U      i) 

'  1 

Ji 

28 


osm:k, 


red  cells,  which  I  shall  speak  of  shortly  in  connection 
with  the  rcj^'eneration  of  the  corpuscles.  They  are  usu- 
ally a  little  lar<;er  than  the  ordinary  red  corpuscles,  and 
the  tint  may  be  slii^htly  paler.  The  nucleus  may  be 
seen  in  process  c^f  division,  and  I  have  seen  corpuscles 
in  process  of  tission,  identical  in  ap|3earance  with  those 
long  ago  described  and  figured  by  Kolliker,  as  occur- 
ring in  the  blood  of  the  embryo.  They  may  be  not  in- 
frecjuently  found  in  groups  of  three  or  four,  close  together, 
or  even  in  contact,  as  if  the  group  had  resulted  froni  the 
division  of  a  single  corpuscle.  I  was  parti<  ularly  struck 
with  this  feature  in  one  case  of  leukiemia  in  which  they 
were  very  abundant,  and  I  regard  the  explanation  just 
given  as  a  very  likely  one  in  the  light  of  the  recent  ob- 
servations of  liizzozero,  upon  the  rapidity  of  the  pro- 
cess of  division  in  these  forms.  That  they  originate 
in  the  bone  marrow  there  can  be  no  doubt,  and  in  my 
e.xperience  it  is  just  in  those  conditions  in  which  this 
tissue  is  hyperplastic,  that  they  occur  in  the  blood. 

A  rare  and  odd  element  in  the  blood  is  the  corpuscle 
containing,  red  blood  corpuscles.  Several  observers  have 
noticed  the  presence  of  red  cells  inside  colorless  cor- 
puscles in  the  circulating  blood.  It  is  very  uncommon, 
and  the  sketches  at  I'ig.  5  represent  the  only  examples 

Vic..  5. 


1 


Corpuscles  containing  red  l)lo  ul-corpusclfs.     t.   From  blood  of 
child  .It  term.     2,   From  Ijlood  of  a  leukiumic  patient. 

which  1  ha\e  met  with.  Considering  the  aljundance  of 
these  cells  in  the  marrow,  spleen,  and  lymph  glands  n 
certain  states,  it  is  surprising  that  we  do  not  find  them 
more  often  in  the  blood.  It  is  quite  possiljle,  how- 
ever, that  the  colorless  corpuscle  circiiating  in  the 
blood  may  itself  take  up  a  red  cell  into  its  interior  just 
as  it  may  an  oil  drop  or  a  particle  of  pigment.  I  have 
a  sketch  of  a  colorless  corpuscle  of  the  blood  of  the 
frog,  with  three  or  four  human  red  corpuscles  in  its  in- 
terior, which  it  had  eaien.     I  have  sought  in   vain  in 


I. 


lAKTWKKillT    I.KCTl'KI'.S. 


29 


chronic  malaria,  for  evi.ience  that  the  leucocytes  in  the 
blood  take  the  corpuscles  entire  into  their  interior  in  the 
formation  of  the  black  pigment.  Thev  would  appear 
to  take  in  the  disintegrated  particles,  possiblv  in  the 
spleen  and  liver,  but  not  the  entire  cells. 

It  is  interesting  to  compare  with  the  sketch  I  have 
thus  given  of  the  state  of  the  corpuscles  in  ana.>mia  with 
the  condition  of  the  blood  in  the  acute  anicmia  follow- 
mg  a  profuse  hemorrhage,  either  accidental  or  experi- 
mentally induced.     With  our  present  knowledge   there 
IS  a  really  serious  difficulty  in   deciding  just  what  feat- 
ures of  the   blood   indicate   degeneration   and  what   a 
process   of  regeneration.     Thus,   the  microcytes    as   I 
have  stated,  are  regarded  b\-  some  as  evidence  of  a  ret- 
rograde process,  by  others  as  indicating  repair  of  the 
waste.     In    an     animal    deprived    of  one-third   of  the 
amount  of  blood,  or    in    an    individual   after  a  severe 
prostrating  hemorrhage,  the  changes  noted  are  almost 
identical  with  those  already  described,    isi.  The  red  cor- 
puscles  display   irregularity  in    size  and    shape.     The 
microcytes  are  numerous  and  resemble  in  all  respects 
those  of  chronic  amvmia.     The  larger  forms  of  red  cor- 
puscles are  not   so  constant.     Poikilocytes  also  occur 
As  the  percentage  of  red  cells  approaches  the  normal 
these  irregularities  diminish  in  a  marked  manner.     2d' 
The    colorless    corpuscles  are   relativelv,  and  mav   be 
even  absolutely  increased  in  number.  '  This  doubtless 
IS  the  result,  in  part,  of  a  relatively  smaller  loss  in  white 
corpuscles  in  consequence  of  their  adhesive,  wall-loving 
property,  and  in  part,  to  the  Hooding  of  the  blood  cur- 
rent with  leucocytes  poured  in  with  the  copious  flow  of 
lymph   which  takes   place  to   make   up  the  volume   of 
blood.     3d.  The  nucleated  red  corpuscles  may  appear 
In    the   experimentally   induced    amemia    in    animals 
(dogs)    they    are    more    abundant    than  after    profuse 
hemorrhage    in    man     (cirrhosis.    h;cmoptvsis).       4th. 
Th?re  is  a  marked  increase  in  the  number  of  the  blood 
plac[ues. 

h\X';u-nUi(m  of  tlw  Coypuscles.—  Yhtr^  is  probaMv 
no  subject  in  physiology  upon  which  opinions  differ 
more  widely  than  in  the  mode  of  formation  of  the  cor 
puscles-particularly  the  red— after  birth.  The  possi- 
bility of  a  solution  of  the  question  seems  to  have  been 
offered  in  the  discovery  of  the  blood-forming  function 


i 


r 
) 
{ 

\i 
c 
1 
I 

I' 

•I 


s 


\\\ 


-:li  k  t 

;    k... 

Pi' 

--.-■ii' 

II 

ijl 

■■ 

wHS' 

I  AK  1  WKK.II  :■ 


URh.S 


of  the  red  in  urow  l)y  Neumann  and  I!i/./.o/ero,  and  the 
positive  assenions  of  llayeni  ie,i,',ndin,n  the  blood  i)laqiie 
and  its  connection  witii  re-:cnciati()n,  have  served  to 
arouse  a>,Min  the  interest  in  diis  impoitant  c|iiestion. 

I  profjose  to  hiy  before  yon  briefly  a  statement  of  the 
rurrent  views,  as  interpreted  in  the  li^du  of  more  recent 
investiKalions,  and  I  shall  tir,t  direct  your  attention  to 
the  stuily  of  the  formation  of  red  corpuscles  in  the  bone 
nianoui. 

I  bc'^in  with  this,  as  I  iiere  fcol  more  at  iiome,  having 
for  some  years  i)een  an  observer  of  this  tissue  in  variout 
states,  and  havin.LC  arrived  at  certain  conclusions  which 
appear  to  me  justifiable.     The  red  marrow  which  in  the 
newborn  and  youn<,r  child  occupies  the  bone  cavities  of 
the  entire  body,  is  confined  in  the  adult  to  the  cancelhe 
of  the  short  and   flat  bones,  but  even  with  this  limita- 
tion tiie    entire    bulk    is  very  t,'ivat,  and  if  massed  as 
one  organ  would   exceed    considerably  tlie  volume  of 
the^  spleen.     Without   entering   into   |)'reliminarv  histo- 
logical details  on  the  structure  of  the  marrow,  which  are 
now  incorporated   in   the  text-books,  [  shall   proceed  at 
once  to  the  consideration  of  the  cell  elements  of  this 
tissue.     With  a  fine  capillary  pipette  a  small  quantity 
of  the  soft  red  marrow  is  placed  upon  a  slide  without 
any  reagent  and  a  thin  cover  applied  with  gentle  pres- 
sure so  as  to  procure  a  layer  of  uniform  thinness.     The 
plasma  of  the  marrov    is  usually   (piite  sufficient,  and 
there  is  serious  objection  to  tlie  addition  of  any  reagent, 
as  the  delicate  colored  stroma  of  many  of  the  cells  may 
be  at  once  altered,      I  feel  sure  that  neglect  of  this  pre- 
caution, so  strongly  emphasized  by  Xeumann,  has  time 
and  again   prevented  observers   from  seeing  the  very 
objects  they  were   in    search  of,  and   thev  have  ended 
with  a  denial  of  their  existence  (Rutherford,  J/isMoj^ry)_ 
Examined  in   this  manner  we  can   usuallv  see  the  Vol- 
lowing  elements:    r.    Ordinary   marrow  cells,    [a)  with 
coarsely  granular  protoplasm   (F^ig.  7. '«).  coarser-look- 
ing than  that  of  a  colorless  blood-corpuscle.     The  nuclei 
may  not  be  apparent  at  first,  but  they  gradually  become 
distinct,  two  or  three  in  number,  oval,  round,  or  reni- 
form  in  shape  and  vesicular  in  character.     On  the  warm 
stage   these  elements  display   feeble  aiiKeboid    move- 
ments. 


b.  Smaller  cells  about  tli 


e  si/,e  of  colorless  corpuscles 


;■■   i 

I-- 

'  ■  1 
I' 

p     i 
1 
I 

I' 

s 

n 
^ 


i   l| 


m 

y  ,  ■ 

M 

1' 

;    I 

fm 

L 

fc^i 

if  , 

» 

!l 

I 

' 

; 

! 

33 


(ISI.l'.K, 


with  more  solid  nuclei  and  less  granular  body  [iroto- 
plasm;  they  art-  not  so  nuiiuroiis  as  the  larj^ei'  cells  and 
some  of  them  may  he  colorless  blood-corpuscles. 

Ki,;.  7. 


#      # 


# 


^' 


(?^ 


n 


(S)  id)  (^^  (^^ 


Cell  elements  of  red  marrow,  a.  Large  granular  marrow  eells. 
i.  Smaller,  more  vesicular  cells,  c.  F'ree  nuclei,  or  small  lym- 
phoid cells,  some  of  which  may  he  evenly  s\u-rouniled  with  a  deli- 
cate rim  of  protoplasm,  d.  Corpuscles  wiili  clear,  translucent 
protoplasm. 

2.  Marrow  cells  (9  to  12  /;  in  diameter)  with  smooth 
homogeneous  protoplasm  (Fig.  7,  </)  and  finely  granular 
nuclei,  indistinct  on  first  examination,  but  becoming 
more  apparent  in  a  few  minutes.  The  protoplasm 
surrounding  the  nucleus  is  translucent,  homogeneous, 
colorless,  and  variable  in  amount.  There  may  be  a 
single  large  nucleus  surrounded  by  a  narrow  rim,  or 
there  may  he  a  dumbbell-shaped  nucleus,  or  it  may  be 
divided  into  two,  or  even  three.  The  jjrocess  of  indirect 
division  of  the  nucleus  can  be  well  traced  in  these  forms. 
Certain  of  the  cells  may  present  the  faintest  possible 
tint  of  color,  and  as  the>-  are  carried  about  among  the 
other  corpuscles  they  show  a  peculiar  flexibility. 

3.  .Small  lymphoid  elements,  resembling  free  nuclei ; 
solid-looking,  homogeneous,  2.5-5  ;/  '^  diameter.  Fig.  7,  c. 
They  resemble  the  smallest  lymph  corpuscles,  but  about 
many  of  tl.em  no  distinct  rim  of  protoplasm  can  be 
seen.  In  others  there  is  a  faint  border  of  protoplasm. 
These  bodies  are  variable  in  number  but  they  may  be 
regarded  as  constant  elements  of  the  red  marrow. 
Identical  structures  may  be  found  in  the  spleen,  Fig. 


i:if 


C.AKTWKKillT    M-CTIKKS. 

■-'     ',-,•  o>  <f.      I  iicy  rani,'e  in 


r^n  toipusU..  u..s.M,.l,hnK  a  and  3  of  ^,  in  all  respects  siv, 
absenee  of  any  trace  of  nucleus. 


ve  in   the 


Sneoits  '^'•^'^';'>' ^■^•-^•"'"ed  the  ptotoplastn  is  homo- 

gcntou.  clear,  and   the  nucleus   indistinct.     The  color 
'^  of  all  grades  up  to  the  intensity  of  an  ordinary  red 

rmf      T      ■■   '":     "''""•>•   '^^  ^'^^  "'■'•'"-•>'   ^°l">-ed 
"tqucntly   seen   ,n   all   .staj,'es  of  division.      It    is    not 

ntc'te  tl  ;;  u'"'"  ?'''  '^^■•■^  "'^  appearances  ^hfch 
•ndtcate  that  the  nucletis  undergoes  changes   pnor   to 


Fit;.  9. 


(^ 


Xiicleated  red  corpuscles,  i 
nucleus  from  the  cell,  a  process 
'11  irrow. 


'"^'ratiuif    the    mi-ration    of    the 
'lot   infrequently  seen   in   the   red 


ini},n-ation  from  it 


thee.^eofthecellasifi;-pr;;esj:f 
l^'S-  9).  'ind  bodies  of 


seen  in  the  i 


snnil; 


mmediate  vicinity  of 


»r  appearance  may  be 


the  red  cells 


'If 


il 


s                          » 

''"'h  I 

i  1I 
I    I 


/ 


11 


ii'ii'l 


f 


■i  1 


) 


.  i 
i 


M 


34 


OSII'K, 


5.  Red  corpuscles  of  ordinary  form  and  appear.incc. 
Upon  their  alMindance  or  paucity  depend  the  color  of 
the  marrow.  In  addition  to  the  usual  biconcave  disks 
there  are  commonly  me<;alocytes,  especi.lly  if  the 
marrow  is  hyper|)!astic,  and  a  variable  mur'.ber  of  mi- 
crocytes.  Tlie  larj;er  corpuscles  are,  I  thin!:,  more  fre- 
cjuent  than  the  smaller  ones. 

6.  Myelopiacpies  or  j^dant  cells,  the  description  of 
which  need  not  detain  us,  and 

7.  Corpuscles  containing;  red  blood  cells  (Ki^^  6,  d,  i). 
Some  of  these  are  evidently  collections  of  red  corpuscles 
imder^oin^  disintegration  to  tbrm  the  cells  containin}^ 
granular  pii^ment  (  Kli;.  f>,  b,  i),  while  others,  resembling 
rather  the  giant  ceils  (Fig.  '•,  'k  3),  may  possibly  bear  a 
different  interpretation. 

The  chi(;f  interest  cenlres  in  the  nucleated  red  cor-  , 
puscle  of  the  marrow  and  of  liie  spleen.  From  what  does 
it  originate  ?  What  is  the  process  of  its  conversion  into 
the  ordinary  red  disk  ?  All  arc  agreed  as  to  its  im- 
portance in  blood-making.  It  is  the  earliest  red  cor- 
puscle in  the  embryo;  it  is  constant  in  the  cytogenic 
tissues  of  all  animals,  .mil  it  would  l)c  unreasonable  in 
the  highest  degree  to  suppose  that  in  the  red  marrow  of 
the  adult  it  was  |)reseiit  for  any  other  purpose.  More- 
over, in  states  of  aniemi.i  and  after  bleeiling,  the  nu- 
cleated red  corpuscles  increase  in  the  bone  marrow  and 
even  appear  (overtlow)  in  the  blood;  and  lastly,  Bizzozero 
has  watched  the  (iroces,  of  division,  which  may  occur 
with  remarkable  rapidity,  within  fifteen  minutes.  My 
observations  lead  ine  to  regard  the  nucleated  red 
corpuscle  as  the  product  of  transformation  of  the  clear- 
bordered  homogeneous  marrow  cell,  as  all  grades  of  tint 
can  be  seen,  between  cells  with  scarcely  a  trace  and 
strongly  colored  forms.  There  is  no  essential  difference 
apparent  in  the  body  protoid.ism,  in  both  it  is  smooth, 
flexible,  and  translucent.  It  is  not  difficult  to  outline 
corpuscles  in  series  from  those  without  a  trace  of  color 
to  forms  well  and  clearly  tinted.  The  colorless  marrow 
cells  with  clear-bordered  pr  jtoplasm  appear  to  be  the 
descendants  of  the  solid  lymphoid  cells — the  primary 
lymph  cor|JUscles — the  |)roioleucocyte— which  grad- 
ually becomes  surrounded  h\  a  zone  of  homogeneous 
protoplasm,  (lertaiidy  intermediate  gradations  can  be 
seen  between  the  forms   figured   at   Fig.  7,  c,  and  the 


smaller  coiniisi  les  at  Fi,r   ,     /     •,., 

formation  of  the  nti,!,.,.    i       ','■  '  '"■"'■'^''  "<"  "■•ns- 

"I'cleus.  as  .ho„„   at   p,,:";' ;'' /''-I'Pearanre  of  the 
impossible  to  drau'    un  mh-M-  .  '  ""''  •^"     ''   -'^'•''"^ 

"f  ^"'.■1>   cells,  an      t'snl     ;""''"'""    ^-m  a  study 
tl'ey  contain  may  be  thT  fl  ■'.'-'"'"ants  which 

f'em  front  ordina  y  r  c'n  ush""  ';'  ^"^''"^'-'"n^' 
servers  have  record  -dn  '7''"^^>'^-  ^  ery  „,any  ob- 
•n.cleus  fro,,  tl  e  eel  .  d  i  "'  ^  '"'''""""  "^  "^'^ 
of  the  process  a!  ep;e  „,  ,  '"r,,-"'^  ^^?"  '"  ^'"  ^^^'^-« 
'^een  able  to  convince  ;,  1 1  ,  1  '•■ '""  '  'V""  ""' 
a  post-mortem  chan>re     S   ,     i  .      ;">'"^'"S  but 

there  are   not  ne  riv  .    ^'"•""'>'  '"  ''^^  fresh  marrow 
P^'-tially  ex  r  de  i     ■    i  '        "•'  .'^"nn.scles  with  nuclei 

modeof  transfornriiir.n         .'^'""^  'his  as   the   normal 

^^.1  observation  ;;:ir ;;:'  z  r'  ^'f  !!"'-■  --e. 

the  nucleus  unden^oeJ  li    L       ^■'""'■"^  "^^  ^■'^'"-  "''-^t 
similar   process  'inv  L  ^T'-''""   "  "^'-"  '"^"'^  "'^^t  ^ 

blood  ceils  o    dt  "m,     .„'"^'"    '"  "^  "-'-'ted   red 

as  the  cells  are  idem  '      "'n  V  '"""  ''  ^'^"  '°' "' ■'"'' 
"cntical   ,n  appearance  and   probably 


CIV 


I'K;.  io. 
p.     tt- 

SI. 


nioorl   of  ...nhryc,.  four  ,„o„,l,s.     ,,13,,      ^     , 
'Corpuscles.      In  a  th*.^,,,,,.  „         1        ,     '  ^' 3' 4-    Auclcaled   red 

">e  nucleus  as  ir;" :'::^'J^'T[  f  ^""^^'  "^P^—  "^ 
3,  onluwry  re<l  corpuscle.  '  ""''■'■'"^yte ;  2,  rnegalocyte  ; 

entires  his  o,-2n''t:'z^?;;!^rS'"'r^^^'^^'^^^^ 

^-rds  the  nucleated  red  ccfrp^sdlas'!""'  7'"!;^'   ''" 
stant  element  derived  bv  f^  r  ^^ed  and  con- 

of  the  san,e  k,n      a  ml     „M  "an™"  '"''"^''"^'  ^°'-'- 
-ent^o.    .,.,,;3  ,,,,-;  ;;>^-Proce.  of  develop. 

The  nucleated  red  corpuscles  are  slightly  larger  than 


11 


I      I 


i     I 


'  i  i 


;  .1 


36 


OSI.KK, 


ortliiKiiv  l)l()iiil-i:<)r|Mis(  Ics,  and  in  si/t-  ifst'ml)le  the 
megalocytes  whiili  art.'  usually  aliimilani  in  the  bone- 
marrow.  Siicli  a  cfU  as  is  rc|)rest;nti'(l  at  V\'^.  8,  fi,  4, 
dift'ers  in  a|)|)iMraii<e  from  tliosc  at  A,  I,  2,  3,  solely  in 
the  absence  of  nuclear  remnants.  In  the  further  i)ro- 
ccss  of  (Icvcloinnent  into  the  ordinary  red  corpuscle, 
we  must  su[)|)ose  ( undensation  of  tlie  stroma  and  a 
chan},'e  from  a  flattened  ((11  to  a  biconcave  disk.  In 
ana  inia  the  me^ahx  ytes  \vhi(  h  may  be  so  abundant  in 
the  l)l(H)(l  are  to  !)e  rei^ardcd  as  imperfectly  formed  cor- 
puscles, whicli,  bom  causes  as  yet  unkn(iwn  to  us,  have 
not  attained  their  proper  form. 

I'ossibly  in  other  ways  the  spleen  aiul  m.irrow  ele- 
ments may  participate  in  blood  formation,  I  have 
already  referred  to  the  lUdcess  of  buddinj;  which  may 
be  seen  in  certain  of  the  led  cells  of  the  marrow  (  Ki;,;.  3) 
and  of  the  s|jleen,and  Mal.isse/  looks  upon  these  gemma: 
as  capable  of  development  into  ordinary  red  forms.' 
The  diffi(  nlty  is  one  of  interpretation  ;  the  process  can 
be  readily  followed,  but,  as  I  mentioned,  it  is  probably 
a  piiysical  chan^;e. 

Within  the  lar^;e  ni\  elopkupies  and  also  in  the 
elonj^Mted  cells  of  the  stroma  of  the  marrow,  there  can 
be  seen,  occasionally,  ii'd  corpuscles,  which  suggest 
(U"ih-lof»iii'iil  not  iiisiitt,\ij,)\ilioit :  inasmuch  as  the  cor- 
puscles are  in  smaller  number  ami  show  no  traces  of 
degeneration.  They  are  figured  at  6  ,(,  i,  2,  3,  from  the 
s|)leen,  and  .it  6  h,  3,  from  the  marrow.  1  ha\e  been 
struck  with  the  close  resemblance  of  such  cells  to  those 
in  the  subcutaneous  tissue  of  the  young  rat,  in  which 
the  process  of  intracellular  development  of  red  cor- 
puscles can  be  readily  traced,  as  shown  by  Mr.  Schiifer. 
Fig.  6  <•,  represents  one  of  these  connective  tissue  cor- 
puscles with  four  developing  red  cells  in  its  protoplasm. 
It  is  ipiite  |)ossible  th.it  in  the  reversion  to  the  embryonic 
or  hetal  state  of  the  bone-marrow,  these  ct;lls  m.iy  re- 
sume their  haniatogenoiis  function,  which  seems  to  be 


'  Creighton  li;is  dcsi-rilicil  tlic  fo:  in.ition  of  colored  corpuscles 
in  blood  cysts  by  budding  from  embryonic  cells  lining  their  walls, 
and  ii  few  years  iigo  |ohnstone  maintained  (.Seguin's  .Xrcliivcs,  vol. 
vi.)  that  the  red  cells  developed  by  budding  from  the  granulnr 
protoplasm  of  the  adenoid  reliciiUim  of  the  spleen  and  lynipli 
glands. 


<'\Kruiii(;i(T  i.i:(  ri'tiKs. 


37 


' ■'  f""™™.  i»  n,,;,  ".; '  ;,:;"'';""n,,;;'  "■'"^" 

.-•-■n.e  in  il,o  cells  „f  ,,c.    ,l?„    F,.,,        •n  ""■"."•■='"•■ 


I 
I 

) 
(' 

I 


;  T  ■ 


"■•""- ^■^' ■■---'-.  I,,,;,;;,;.?..;,::  r:2,;^ 


1 

i'       ^ 

H 

A 

] 

,\ 

i 

J 

Mi 


!    I 


38 


OSLER, 


B)  ^      ^"  ^'l 


h 


group  of  elements  from  tlic  spleen  with  the  blood 
plaques,  five  or  six  in  number  :  i,  are  of  various  sizes, 
and  presented  a  pale,  faintly  granular  protoplasm  ;  at 
2,  were  seen  two  microcytes,  resembling  more  closely 
miniature  blood  disks  than  the  form  rejjrescnted  at 
Figs.  I  and  4,  but  though  resembling  in  size  the  larger 
plaques,  the  appearance  is  totally  different,  and  forms 
intermediate  between  them  are  not  seen.  A  strong  point 
in  Hayem's  theory  is  the  abundance  of  the  plaques  under 
the  very  conditions  in  which  the  corpuscular  production 
goes  on  rapidly:  (i)  in  the  embryo  and  newborn,  (2) 
after  hemorrhages,  (3)  in  the  stage  of  convalescence 
from  acute  diseases.  So,  also,  in  chronic  wasting  dis- 
eases, and  in  certain  forms  of  anaemia,  Lheir  prevalence 
may  be  reasonably  explained  by  failure  to  develop  into 
more  mature  forms.  We  enter  here  the  region  of  hy- 
pothesis, and  it  must  remain  for  future  observers  to 
determine  the  precise  position  of  the  plaque  in  the  de- 
velopment of  the  corpuscles.  There  is  remarkable 
unanimity  of  opinion  among  those  who  have  lately 
worked  at  the  subject,  to  the  effect  that  the  evidence 
is  at  present  altogether  insufficient.  Afanassiew  is  an 
exception,  but  he  holds  that  the  plaque  develops  into 
the  nucleated  red  blood-corpuscle,  the  nucleus  of  which 
is  in  turn  extruded  and  becomes  a  plaque. 

The  observations  of  the  past  ten  or  twelve  years  have 
led  us  away  from  the  old  view  that  the  red  cells  are  de- 
rived from  the  colorless  corpuscles.  ICxcept  in  the 
mode  I  have  indicated  in  the  marrow,  there  is  no  evi- 
dence in  favor  of  the  conversion  of  the  colorless  cor- 
puscles into  colored  for;  ■•  ,  .Mid  the  opinion  is  gaining 
ground  daily  that  the  (.  c.stitute  separate  elements 
with  important  function  ;  ..le  apart  from  regeneration 
of  the  red  cells.  They  constitute  so  many  masses  of 
primitive  or  basis-jirotoplasm  which  may  be  called 
upon  in  the  repair  and  reproduction  of  tissues  and  in 
the  healing  of  wounds.  They  act  as  scavengers — 
p/iiiilocy(fs—\n  the  removal  of  dead  parts,  or  enclose 
injurious  particles  in  their  interior,  and  so  render  them 
inert.  The  leucocytes  of  the  body  have  been  compared 
to  a  standing  army  ready  to  resist  invasion,  and  intlam- 
mation,  in  which  they  play  such  an  important  part,  is 
but  a  battle  by  which  they  protect  tlie  organism  against 
injurious  agents,  such  as  microorganisms.  The  researches 


1 


CAKTWHICJllT    I.F.CTURKS. 

Of  Alctschn.kon;  Lavdowsky,  and  others,  have  so  mate- 

1  te    .;  1     ^  "'  P™«en>tor.s  of  the  red  corrni.cles. 

A  fe,  all,  the  most  .s„hd  acquisition  to  our  knowledge 
of  the  process  of  regeneration  of  the  corpuscles  if  he 
pan,npatK,n  in  the  adult  of  the  bone  n.urow   an      t  le 

c^u;  rs;L  H ' '■"' '^"■•'"^^'^^ '^•""-^---'-'^ 

•-oloiiebs  cells.     Here  we  seem  to  tread  on  a  firm  nun 
.-nt  of  caref^dly  observed  and  well  work::/;;        act" 

xst^  ::;;:'"  ^'^^.^^'f-  '^-"^^-ul  uncertain.vstiH 
P  ore's  '  r'  ■■  '"  "^'i'  "'""'  ^'''-'  ■^"'«-'"  ^''-••-  i"  "-■ 
drvTi;;d,r;r  '"°^'  "''^"■^■^-^  (Ne,nnann,would 
cle  in  i?'  ,'■  "  f  T"''^'^^'  •"'"••"'"i'^n  of  red  corpus- 
tl  ,         h  ■  """^  ^'"^  "^■'■^'^"^'-'  '-^  ^-fi-'-i'-nt  to  show 

de  pen      tl  af';;  ■    "   ""'  ''^/"'•'■'-^-'■'   -    ''-    subject 
lowstlu'l  '---^yenerat.on   of  the   corpuscles  fol- 

Seneial.     In  the  adult  body  there  are  permanent   and 
t> ans.tory  tissue  elements,  and  to  the  latter  the  bloo 
corpuscles  undoubtedly  belon,.     The   uutritio  he 

fo.mer  .s  entu-e  y  uUerstitial,  and  does  not  involve  anv 
change  ,n  the  element,  when  once  fullv  developed      Of 
..n.Ujry  elements  the  epidermic  tis.,es  are  \S^ 
examples       Ihe   epithelium   is  in    constant  process   of 
.egeneration.  and  the  sheddin,  of  the  superficial  eel  s  is 
analogous  to  the  destruction  of  the  older  red  co    n,s  le 
The  new  growth  takes  place  by  the  constant  fissu.n  an d 
'""Itiplication  of  the  cells  of  the  deeper  part  of  ^. 

'"ua>su..  and  if  the  entire  thickness  of  a  portion     ftht 
epidennis  ,s  reuK.ved  by  accident,  the  remnan    o     1  c' 

in  7T  '"  '■'"  '^'^'■'"'"  '-^l^^'''-  'l'-^   1««^-     Just  so 

•n  he  life  history  of  the  blood  corpuscles,  wh  .h  a.x' 
fleetmy  structures,  l.ke  the  epithelial  ;:ells,  the  h.em  o' 
genous  fssues-spleen,  bone  n.arr.nv,  Ivmph  '  hnds- 
contam  as  permanent  elements  cells  which  by  fission 
nuit.ply  and  pass  into  the  blood  current,  more  t^^s 
niociiied,  as  the  red  and  white  corpuscles 
_  The  recent  increase  in  our  knowled-e  of  the  chan-es 
-n  the  corpuscles  in  disease,  and  of^he  proce  e"  of 
reproducttun,   is   an   earnest   of  fuller  info'rmatbn   in 


.1 

■1 

/i' 

i 

,      1 
'i       i 

t 

k 

1 

M 

Tl 

^^^^hiI 

i<  iH!  1 

4° 


OSI.KK,    (AKTWKKJHT    I.KfTrUIS. 


li 

ih 

; 

|j 

■ 

ill 

•5 

tlie  near  futiiie.  A  key  lo  the  solution  of  many  prob- 
lems in  patlioloi^y,  will,  I  doubt  not,  here  be  found,  but 
in  seeking  it  let  us  not  for^^et  that  the  corpuscles  float  in 
the  blood  plasma,  the  patholoj^'ical  relations  of  which 

v'hich 
^•ledtje 


await  investigation,  and  offer  a  field  for  researc 


should  be  ecpially  fruitful  in  adv 


inciniT  our  knowie 


ol 


the  ultimate 


:csses  of  nutrition  and  of  those  devia- 


tions from    it   which   lie  at  the   very   root  of  so  manj 
chronic  diseases. 


"■fl^t.- 


^FCTURI^    III. 

THE   kl.:i,ATi()N  OF  THK  CORPirsciFS  TO 
COAGULATION  AND  THKOMHOSlf 


^  the  a.i         ,,,,,,,,,-- --^^ 
ecij,e   nt   the   ((iiiiU'ctKjn    hctuc.-n    thnc^   „i 

co..«.,i  u,„„  .u;.,  r,,„„  ,i,,  :,i;:s;;,;:;  ,fi™™;;,-;<' 
i  .■.-*:  T„"'  ::,':;.':,":■  ■";':■■'  -' -  ■■'"«!  »"■;,„" 

.cvuda.,     ;■;;,,       ;',V"''  '■"  l"'l>''».  •<•  wl«»e  re- 

-^ *"««  i""'»;r  ,!:;;,;;™™r;:;:;^,S!--'"  °^ 

remains,  consistin,,'  of  plasmi  with     f  >       ■      ^''' 

colorless  cun.us.Jos     \        t  ''*'''  ''"''  '"'^"y 


'Ml 


J|: 


i 

r,''  )■ 

f 

'f  i^    {il 

n 

If 


42 


OSLER, 


li 


I 


I 


,r<\ 


colorless  corpuscles  which  have  undergone  destruction  in 
the  process  of  the  formation  of  fibrin,  and  Schmidt  and 
his  pupils  estimate  that  at  least  seventy  per  cent,  of  the 
colorless  corpuscles  undergo  destruction  in  this  way. 
They  found  that,  instead  of  15,000  colorless  corpuscles 
in  a  cubic  millimetre  of  the  plasma  before  it  is  whipped 
—z.  c,  befoic  *he  fibrin  is  (.-xtracted— there  were  subse- 
quently not  more  than  4000  pcrculMC  millimetre  remain- 
ing in  the  serum.  Kxamining  the  clot  so  obtained,  it 
is  stated  that  the  colorless  corpuscles  have  laigely,  if 
not  entirely,  undergone  destruction  in  the  formation  of 
fibrinoplastin  and  the  liljrin  ferment.  This  is,  perhaps, 
the  most  convincing  experiment  which  any  one  of 
Schmidt's  pui)iL,  has  brought  forward  to  sustain  the 
view,  that  colorless  corpuscles  undergo  destruction  in 
the  process  of  coagulation.  There  are  many  other 
points  urged  by  Schmidt  to  which  1  need  not  refer,  as 
they  are  readily  accessible  in  the  works  on  physiology. 
The  researches  of  Wooldridge'  have  also  shown  that 
the  colorless  corpuscles  play  an  important  part  in  the 
formation  of  fibiin.  He  has  been  able  to  procure  leu- 
cocytes from  lymph  glands  in  a  tolerably  pure  condi- 
tion, by  means  wliich  he  has  described  at  length  in  his 
paper.  These  leucocytes  when  added  to  an  equal 
volume  of  a  ten  per  cent,  solution  of  common  salt  seem 
to  be  converted  into  a  material  resembling  very  closely 
ordinary  fibrin.  By  ex])erimonting  with  what  is  known 
as  peptone  plasma  he  has  obtained  very  striking  re- 
sults which  would  appear  to  indicate  still  more  clearly 
that  leucocytes  play  an  important  part  in  this  process. 
Peptone  plasma  is  obtained  by  injecting  peptone  into 
the  bloodvessels  and  then  bleeding  the  animal.  Co- 
agulation is  prevented  entirely  by  the  inthience  of 
peptone,  and  the  red  blood  corpuscles  may  be  en- 
tirely removed  from  the  serum  by  the  centrifugal  ma- 
chine. This  plasma  shows  no  special  inclination  to 
coagulate,  and  is,  of  course,  particularly  suitable  for 
experimental  purposes.  If  t'^e  leucocytes  prepared 
from  the  lymph  glands  be  added  to  thi~-  plasma,  coagu- 
lation at  once  occurs.  If  a  small  quantity  of  leu- 
cocytes is  added,  the  amount  of  fibrin  produced  is 
small ;  if  a  larger  quantity  is  added,  more  iibrin  is  pro- 


1  Proceedings  of  tlie  Royal  Society  of  London,  18S1. 


> 


CARTWRIGHT    LECTURES. 

duced.    In  f^ct,  Wooldridge  has  shown  that  the  amount 
of  fibnn   produced  in   the  peptone  plasma  is  ^ec  h 
proportionate  to  the  leucocytes  added      The  leucocvte 
seem  themselves  to  form  the  tibrin-perhaps      e  em  re 

as  tlie  ueyht  of  the  leucocytes  added.     Moreover  the 
album.ns  ,n  the  peptone  plasma,  after  coagula.l    can 
be  shown  not  to  have  undergone  any  change  bJt  re 
mam  the  same,  quantitatively  and  qualitatively -and  a 

rssrti^:;^;:'^^'^"--'-------^^ 

vens  the"  T-  '  '-.°"'>'  "^^  ^^^^  P'---^  -'ich  con! 
nTn  M     ,  ^'  '.'  T  ^''""'  ""'  '^'^  '"j'-^^tion  of  leucocytes 
mto  the  blood  of  the  living  dog  produces  no  efiect    ' 

buch  tacts  appear  to  show  very  conclusively  that  the 
corpusc  es  do  undergo  disintegration,  and  4t  if  the 
blood  p  asn.a  of  the  horse  is  examined  after  i  has  been 
wlnpped  leucocytes  may  be  found  in  the  serum  and 
also  m  the  clot  which  has  been  produced,  so  tha  all  the 
leucocytes  have  not  undergone  destruction.     The  el  st' 

ha  Vc  urre??'"  ""'"'--^  ^'^  '— ytes  after  clot  ing 
has  occu.red  has  caused  one  of  Schmidt's  pupils  HeyP 
to  duMde  the  leucocytes  into  two  sets :  the  alpha-^uco 

ot  a  leucocytes,  wh.ch  remain.  From  observation  I  do 
no   beheve  that  the  number  of  the  leucocytes  wLich  un- 

nvth'in'rhr'""  "  '"  '^'""'"^^  °f  ^'-  ho-«'^  Wood 
A?;,        ?  '''f''  '°  extensive  as  Heyl  states. 

oftl  "cotlef  T'"'""  '"  ''''''  °f  ^'^^  ^1-^-^tion 
o  the  colorless  elements  seems  conclusive,  yet  if  the 
hbrm  formation  is  studied  under  the  microscope  it 
appears  to  take  place  without  any  disintegration'  o 
colorless  corpuscles,  and  it  is  extremely  difficul  °o 
demonstrate  their  participation  in  the  process  As  1° 
e    known.  ,t  can  be  studied  in  a  blood-drop  e.xamined 

The  dm'  '"T'  r';  °'''  '^"^^  ^^'"'  ■"  ^'^^  --' '  chamber 
rhe    .me  winch    elapses  before  coagulation   begins  is 

conditions.     Usually,  however,  from  fifteen  seconds  to 
twoor^ejmm^  elap^         the  first  appearance 

'  Dorpat  Dissertation,  Foitschritte  der  Medicin.  1883." 


':  ( 


1  'S( 


a, 

3 


( « f 


3 

i 

5 


Ff 


% 


i. 


f  ^1 

4 


m  ^  I. 

T   ?!       )         " 


I      i        :■;■  !  !  I  s  * 


44 


OSI.ICK, 


i  I 


of  the  fibrin  filaments  is  noticed.  A  slide  can  be  pre- 
pared in  a  very  few  seconds,  and  there  is  sufficient  time 
before  clottini,'  bej,nns  to  examine  the  colorless  corpus- 
cles, the  red  corpuscles,  and  the  blood  platpies.  I  must 
say  that,  in  a  very  careful  examination  of  the  process 
of  the  formation  of  fibrin  in  this  way,  I  have  never  seen 
any  appearance  in  the  leucocytes  which  would  indicate 
that,  as  the  fibrin  was  formed,  they  underwent  disinte- 
gration or  dissolution.  On  the  contrary,  they  seem  most 
stable  elements,  and  the  ama;boid  movements  persist 
long  after  the  fibrin  network  is  thick  and  dense  in  the 
field.  Certainly  in  the  microscopical  examination  of 
the  ordinary  slide,  or  in  the  examination  of  the  blood- 
drop  in  a  moist  chamber,  I  do  not  think  anyone  has 
seen  the  direct  tlisintc.t;  ration  of  leucocytes  in.the  produc- 
tion of  fibrin.  An  iiUercstini,'  and  instructive  experi- 
ment is  to  draw  the  blood  of  a  fro^c,  or  of  the  horse  (in 
which  Schmidt  and  hi-  pupils  hold  that  the  colorless 
corpuscles  so  '-apidly  u  .ergo  disintegration),  into  a  fine 
capillary  tube  in  which  the  process  of  clotting  can  be 
watched  under  the  microscope.  At  first,  the  entire  tube 
is  filled  with  corpuscles ;  but,  before  long,  it  is  seen  that 
theclot  contracts,  and  there  is  a  peripheral  layer  of  serum 
squeezed  out.  In  a  short  time,  leucocytes  can  be  seen 
emerging  from  the  clot  in  numbers,  either  squeezed  out 
or  migrating  from  it.  This  experiment,  which  can  be 
readily  demonstrated,  forms  an  admirable  mode,  as 
Schiifer  showed  some  years  ago,  of  studying  the  process 
of  coagulation. 

A  study  of  die  histogenesis  of  fibrin  as  seen  in  the 
moist  chamber,  in  the  capillary  tube,  and  on  the  ordinary 
slide,  affords,  1  think,  no  evidence  in  favor  of  the  de- 
struction of  the  colorless  corpuscles,  but,  on  the  contrary, 
is  directly  oi)posed  to  this  view.  In  a  certain  number 
of  instances  the  aggregations  of  blood  plaques,  to  the 
connection  of  which  with  the  process  of  coagulation  I 
shall  shortly  refer,  have  possibly  been  mistaken  for 
colorless  corpuscles. 

The  relation  of  the  n'(f  corpiisih's  to  coagulation  is 
not  regarded  as  very  important  ;  they  play  a  more 
passive  part.  But  Landois  and  others  have  described 
a  process  which  can  be  readily  seen  in  the  blood  of  the 
fro"  and  in  mammalian  blood,  examined  in  serum. 
If  we  take  the  blood  of  the  frog  and  examine  it  in  the 


cAK-MVKif.irr  i,i:(  TIKIS. 


45 


serum  of  the  blood  „f  the  rahhit,  it  will  be  seen  that 
the  red  corpuscles  of  the  tVo.Lr  crowd  into  colinnns 
and  in  a  short  time  the  luemo-l<,bin  leaves  the  corpus- 
cles which  become  ^Manular,  ami  librin  filaments  form 
in  then-  vicinity,  and,  according'  to  I.andois,  the  red 
corpuscles  break  d<,un  into  a  material  which  resembles 
granular  fibrin  very  <  losely,  indeed.  These  observa- 
tions were  made  ten  or  eleven  sears  ago  bv  Landois 
and  they  have  been  confirmed  by  others;  Init  whether 
the  corpuscles  undergo  transfnrmation  into  the  fibrin 
hlaments,  or  whether  tlbrin  only  clots  about  these 
groups  of  corjjuscles  under  the  inlliicnce,  perhaps  of  a 
ferment  which  they  extrude,  it  is  impossible  to  say' 

The  relation  of  the  blood  pi.u/ucs  to  coa,t;ulation  is 
particularly  interesting,  and  is,  at  present,  attractin<r  a 
great  deal  ol  attention.  '^ 

In   the  study  of  fii)rin   formation,  as  seen   under  the 
microscope,  it  has  long  been  noticed  that  the  fibrin  fila- 
ments spread  out  ;o  distinct  rays  from  the  minute  a-- 
gregations  which  have  been  kn,.wn  as  .Schultze's  granu- 
lar masses.  Si  liultze  noticed  these,  as  did  also  Ra'^nvier 
in  1873,  who  regarded  these  masses  as  centres  of  coacr. 
11  ation      That  the  filuin  sets  in  a  thick,  dense  network 
alK)iit  the   phupies  is   readily  seen,  but   it   can   also  be 
noticed    particularly   if  healthy  blood   is  examined  in 
which  the  plaques  are  not  very  numerous,  that  the  fibrin 
also    appears   quite   independentlv  of  the   plaques      It 
forms  as  distinct  little  needle-shaped  bodies  presentincr 
an  appeann'-e  not  unlike  that  of  crvstals.    That  these 
crystal-like  portions  of  fihri,,   appear  in  regions  of  the 
held  quite  apart  from   the   blood   plaques, 'is  well  seen 
m    studying   the    i.rocess  of  coagulation   in    the  moist 
chamber.  Althou-hthe  fibrin  needles  when  first  formed 
may  appear  in  portions  of  the  Held  unoccupied  bv  blood 
plaques,  yet  the  network  is  usually  most  dense  in  their 
neighborhood,  and  when  the  entire  field  is  covered  with 
hbrin   hlaments,  the  disinteK.ated   blood  plaques  look 
like  centres  fr,,;n  which  the  filaments  radiate 

The  relation  of  the  bhuul  plaques  to  co.igulation  as 
examined  experimentally,  is  even  more  interestin<^  '  If 
an  ordinary  ligature  is  passed  through  the  femoraFVein 


of  a  dog  and  allowed  t 


or  even   less,    the   tl 


o  remain  for  live  or  six  minutes 


ircads    b 


ecoiiie    coated    with    the 


\ 


. 


)        ■'    i  1 


i 


,  1 


If^ff 


I  ■ 


r 

1     ) 

1;';  )■ 
\-  I 

,-/  I' 


■■;     . 

•;■  1    :  ■ 

l\ 

■'■  I'     ■'  , 

'4  ; 

A  'i 

-,   i 

1' 

s 

i  ■ 

A                  ,            1 

ll 


j    tl 


M^' 


\    '     J  !    M^ 


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T 

^-ii' 

1 

H 


46 


OSLER, 


plaques,  as  represented  in  Fig.  i.  It  is  well  to  separate 
sli^ditly  the  filaments  of  the  thread,  and  if  exposed  to 
the  blood  stream  for  as  long  as  ten  minutes  they  be- 
come uniformly  beset  with  the  plaques.  A  few  white 
corpuscles    may   be    entangled    among   them,  but  un- 


I'lU.  I. 


Aggregation  of  plnques  on  a  thread  of  cotton   passed   through 
femoral  voin  of  dng  .ind  allowed  to  remain  ten  minutes. 

doubtedly  the  p]ac|ues  are  the  first  elements  to  aggregate 
about  such  a  foreign  body.  The  outlines  are  usually 
distinct,  but  if  allowed  to  remain  long  in  the  vein  those 
nearer  the  threads  become  more  granular,  and  the  dis- 
tinct corpuscular  nature  is  less  evident.  If  a  small 
brush  of  thread  is  tied  to  the  end  of  pen-handle,  or  any 
suitable  object,  then  whipped  in  the  blood,  as  freshly 
drawn,  for  four  or  five  minutes,  and  then  examined,  the 
brush  of  threads  will  have  precisely  the  same  appearance, 
and  are  uniformly  covered  with  blood  plaipies.  The 
colorless  corpuscles  are  adherent  here  and  there,  but  the 
blood  plaques  form  the  striking  elements.  They  adhere 
to  the  filaments  of  the  thread,  and  several  of  the  finer 
fibres  of  the  thread  may  be  entirel)  agglutinated  by  the 
aggregation  of  the  blood  plaques  about  them.  1  can  fully 
confirm  these  original  observations  of  Bizzozero  and 
Hayem,  and  the  experiments  have  now  been  repeated 
by  a  number  of  observers.  If  the  threads,  after  having 
been  whipped  in  the  blood,  are  carefully  washed  in  a 
saline  solution,  all  the  red  corpuscles  can  be  washed 
away,  so  that  few,  if  any,  ran  be  seen,  and  then  if  thcse 
threads  are  dipped  into  a  coagulable  solution,  clotting 
will  occur.  This  experiment  was  performed  by  Biz- 
zozero  in  1882,  and  has  been  repeated  by  other  ob- 
servers. It  has  been  urged  against  it  that  possibly 
the  threads  beating  about  in  the  blood  have  absorbed 
some  of  the  fibrin  ferment.  This  is,  of  course,  possible, 
but  certainly  in  such  threads  the  chief  elenients  to  be 
seen  are  the  blood  ])laques,  and  the  leucocytes  are  very 
scanty  ;  besides,  the  greater  the  number  of  the  blood 
plaques  adherent  to  the  thread  the  denser  the  coagulum 


(AKTWKK.MT    I.IJ  Tl'K  KS. 


47 


Will  be  as  if  the  blood  phuiues  furnished  the  mate- 
rial for  the  production  of  the  fibrin  or  the  ferment  in 
larj^re  c|uantity. 

Still  more  conclusive  evidence  of  the  participation  of 
tlie  blood  pla(|ues  is  their  relation  to  thrombi  as  exoeri- 
mentally  produced.  ' 

The  femoral  artery  of  a  do-  is  exposed  and  a  linear 
s  it  made  ,n  the  vessel,  through  which  the  animal  is 
allowed  to  bleed  to  death,     This  portion  of  the  vessel  is 


Fn;.  2. 


1^ 


Section  of  f.M.oral  artery  of  clog  at  the  .ite  of  longifiulinal 
Hcision  through  winch  .ho  animal  bled  to  death.  (Cut  n  the 
obhcuely  low  power.)  i,  .,  3.  Adven.itia,  media/and  elasUc 
lamma  of  nilnna.  4.  Aggregations  of  blood  plaques  in  enormou= 
numbers  about  the  in.iuia  and  the  cut  margins  of  the  vessel,  c' 
C  o.  co.nposed  ch.eHy  of  red  corpuscles.  6  X.  The  cut  end  from 
which  !•  ig.  3  w:is  sketched. 

rapidly  excised  and  placed  at  once  in  alcohol,  or  still 
better,  first  in  osmicacid,  and  then  sections  carefidlv  cut 
through  the  part  where  the  incision  was  made,  when  such 
an  appearance  as  seen  in  Fig.  2  will  be  found.  Occupying 


c 

i 

:    ;    :5  !■•' 

.  )     ■  ■ 

Jl    ' 

[I 


:   I 


1:  »■ 
i 

f  ' 
I' 
c 


!•    I 
I' 

3 


I     1 


1 

I  m 

1  Mull 

m 

:.-%  n-  ill  I 

,||li  r:| 

1 

•;  ■    J  _ 

1 

l*jj^''. 


Mi 


48 


i»SI.Kl(, 


the  cut  cd^iis,  ,111(1  tillinj^  in  plait's  tlu'  liinifii  dt'tlie  ves- 
sel ii  finely  ]^'riimiiar  material  is  seen  muler  a  Idw  jiouer. 
Siirroiiiulinf;'  it,  to  the  mitside,  as  represented  a!  5  in  the 
ti;^ure,  there  is  ii  darker  material  made  up  hn^uly  of 
dark  clots  coinpused  of  red  blood  corpiisi  les.  In  tiie 
centra!  port'on,  in  imnudiate  i(jnta(  t  with  tin;  cut  edj,'es 
of  the  vessel,  in  contact  with  the  elastic  lamina  of  the 
intinri,  and  ucctipyini;  the  ir.terstices  of  the  ra^^'i^^ed  sui- 
faces,  are  the  blooil  piacpies.  This  was  so  stated  liy 
Bizzozcro  in  1882,  .and  it  lias  betn  conlirrned  in  an 
elabor.ite  investi,i,'ati(m  from  the  laboratory  of  Lan^- 
hans,'  in  lierne.  M>'  own  o!;servations  are  in  harmony 
with  these,  and  we  may  say  tiiat  the  platpies  are  the 
elements  which  fust  settle  on  the  edges  of  a  wounded 
vessel  and  whii  h  form  the  basis  of  the  thrombus. 

Fij^.  3  represents  the  entl  of  a  [xirtion  of  the  adven- 
titia  indicated  by  a  -loss  (>:  )  in  Fig.  2.     The  sketch 

FKi.  3- 


:lll 


ICiul  of  small  portion  of  advcntisia  iiidicati'd  at  >'  in  Fij^,  2. 
TliL'  fibres  arr  cvcrywhi'i-t'  sunonmk'il  witli  ynmulur  disintegiating 
pkuiues. 

shows  the  blood  plac|ues  in  a  condition  of  granular  dis- 
integration, but  under  a  high  power  the  outlines  can  be 
distinctly  defined,  and  any  one  with  a  knowledge  of 
these  elements  and  of  the  changes  they  undergo  has  no 
difticulty  in  recognizing  them.  If  the  cut  ends  of  the 
vessel  are  examined  when  fresh,  in  osniic  ai  id  or  Pacini's 
fluid,  the  elements  are  still  more  clearly  seen  and  are 
readUy  determined  to  be  identical  with  those  iii  the  cir- 
Lulating  l)lood  and  in  th'-  gr.uuile  masses.  The  elabo 
rate  investigati(;ns  of   Eberih,  published  in  the  January 

1   Lubnitzky,  .Archiv  (.  lixp.  I'alli.  u.  I'liann.,  1883. 


I' 


•AKTWRIfjHT    t.K(TIM<KS. 

number  of  Virrhou's  An/iivr,    ixsr,      i       i       , 
stratethat  the.,I.„„n.  ,  '   '^'^^''  '  It'^'i'v   (lemon- 

aiJpearixl  to  prove  l,v    I   „h  >  "ilcrcslins.    Znhn' 


*>  (y  ,^  y>^ 


( .J 


Plaqufs  fron,  ,h,n  do.  on  w:,rtv  endocarditis 
ncross  a  v.b»1  In  ,l,c  o„,.„  „„,  or   „  ,1  c      .^J  ,'"""' 

;    -'tihre^attci   masses — w  iitp   thromhi      ti 

^i^::<i;^rri::i,'-3S  T  T: 
in  osmic  acid   Pac  n?!  I      '"■'  ''^  ^^  ^^'"'^  'trombus 
'  Virchow's  Arc'aiv,  Bd.  63, 


f'^    j 


C       ! 


' 

1    J- 

:  i 

I. 

"1 

It 

1 

1      s 

1 

' 

: 

1 

i:  i     ■ 

■\ 

■J1  .i 


■  "  V         '    '                 '    ' 

1 

'  ^  '  !  '■ 

J 

J 

1 

n  \M 


5° 


(ISI.KK, 


plaques  will  reiulily  re.nj,'nize  as  Muh.  Fig.  5  represents 
two  or  tliiec  while  tlnoinbi  in  tlic  anrta  imnicdiately 
rtbove  the  bifurcation .    'I'lie  case  was  one  of  lanrer  of  the 

Fi(i.  5. 


Whit';  lliroinl)!  composed  almost  entirely  of  blood  plaques. 
Abdominal  aorta.  Woman  dead  of  cancer  of  the  stomach. 
From  specimen  in  Museum  of  McGill  Medical  Faculty,  Montreal. 

Stomach,  and  when  the  aorta  was  slit  open  these  masses 
were  seen  looking  as  if  a  neoplasm  from  the  retroperi- 
toneal glands  had  perforated  it.  They  were  grayish- 
white  in  color,  soft,  and  on  examination  were  seen  to 

Fill.  6. 

Plaques  from  specimens  illustrated  in  Fig.  5. 

be  composed  of  the  elements  shown  at  Fig.  6.  There 
could  be  no  doubt  as  to  their  nature  ;  they  were  blood 


I' 


'AKTWKI.niT    I.KCTUKKS.  ., 

pl.i.|iies,   prfscntin.'  the  lirrnl.r    . 

i'-'.lo.  the  nan-owlinc^/,:",,'r'^>';-;:'  --'-'■' 

wastheHr,st  spcd.nen   n/u     ,        '      "'V,''''''"';    '^''"-^ 
strate  that  the  white  il,mn,i  '  ''''''-'  '"  'Ifmon- 

--i-  „,y  observation    f  .,.:^;r;r'"   ''^"'   '"''^" 

ve;;ctations  on   the  v a  v  '     f  ' '"mertHMi  with 

'''-e  specially  i.te^"'  2'       ""•     '"■'""<'-•< 
ob.serve  the  white  thr,  n    i   1  '"'"'";"   ''•"■^■'"^'">    '" 

ficial  parts  of  ti,e        n  ''  ''•""'"'^">.v  die  super- 

C""'P<.sed  not  oC  c      ,  "    "'^^'P'^'-'n  they  are 

'"-tecl  hbrin    netv,   k    1  "  ""''U-s,  les,  nor  of  a  reticn- 
Plaques  which    ithe  '  -^'  luMVely  of  these 

.ranularclisinuJ,':  J  ;^';;;\r''^-'-ve  undergone 

and,  in  the  ^ame  veTi-  l.v  u  '  '^>  Bi/xo/tio, 

•-ennotedhy;.-S.:;>^JX;r^'"'^'''^'-'''- 

aorllf ■wL;h'::::^l,r,;'r"  ----  -'  "-  thoracic 
soft  grayish-whii;^  :;::':;;-;;-;;-- a  number  ^ 
'''servers  have  noted  On  '  ''"-.'•'"""-.  -uch  as  nil 
'""ndtobeniadeuoofH  '^•^a'"'"^"""  ^Lese  will  be 
compose  the  li  e  thn  n  b;'":"''  T'"''.'"  '"  '''"''  -'^-h 
"i^k-'^ke  blood  ,^  r  •  r  ,^'' '"'"^">' ^''•^"'-■ 
bodies  under,.o  are  'erv  pec  ,  "  a"^^'  "'^"^'^  ^'^^^« 
■">■  first  lecture,  they Vonel  i  ^'  '  ""'"ioned  in 

are  withdrawn,  and  tl  e^  '  '"'''^"  ^^'^  ^'"^  ^^^  ^hey 
mation.  whereby  le  l,se  r'^"  ^-{-rkable  transfer- 
converted  into  \  j;;;^^;;  S:..°r  '?^..?-!  -on,e 


^.viduaipia,ue;b^r;;:rr:;:;::,:r^!-''r'"- 
=^.i:^nti^:;::;r^----vt;.n/;h;i:':E 

-edini.;tth:'^bL;;;rp;;;.;;2fi,rr'"^'^^^-- 

and  become  irranul  ir  -.„  i  '^  ''"-'  ''''f'  fl'-^'inteorated 
recogni.able;^;^  ,;';,"?*-:  ""  '""«-"  distinctly 
tinct,  their  outlitt'  J  "e     ^  .n';  l'h^'  ""'^'  ""^^^  ^i^ 

2i;v::-r--"--"^^ 


I 


r 
) 
i 
I 

I*     t 
p 


I' 

3      .5 
it 
,\ 
i 


i-  h 


ii 


)  I 


f-'f 

r. 

t  MBM 

■  i 

s 

'  BH 

<   -S 

1 

if 

52 


OSI.ER, 


dence   of  this    important    jioint    on   a  firm   basis,    and 
explain    the    production    of    white    thrombi.       In    the 


Fig.  7. 


.Small  aneurism  of  thoracic  aorta,  showing  the  internal  wall  of 
the  sac  covered  with  numerous  curvilinear  eU-vations,  grayish- 
white  in  color,  an<l  composed  of  blood  plaques.  Specimen  in 
Museum  of  McGill  Medical  Faculty,  Montreal. 


ra 


vess 


pidly 


circti 


latins   blood,    the    ceiural  portion   of  the 


el  is  represented  liy  a  dark  line  in  which  you  see 


CA RTWK IGHT    LEf TU K KS. 


53 


no  corpuscles  whatever;    nothing  but  a  red  streak,  on 
e.  her  side  o      .h.ch  there  is  the  so-called  still  la  -er 

r '::;  zt .  f  '"""t^^-  '^''^^  '-^p--"'^  ^^e  biS 

become    s  Tk  '■^^P"'.^""^i'i°"-     If  the  circulation 

becomes  slower,  then  >t  is  seen  that,  in  addition  to  the 
leucocytes  which  collect  in  the  still  layer,  tC  Llood 
P  aques  appear;  but  in  the  rapidly  circulatm.  b  ood  as 
'^een  m  the  mesentery  or  the  omentum  of  the  JLl- 
P.g  or  the  rabbit,  the  still  layer,  the  peripheral  no  tion 
contains  no  blood  plaques,  and  only  occa's.onally       eu 

Fbe n     1  '^'"'^^7^^^'  '^y  ^  distinct  tube  of  plasma, 
-be.tl    bnngs  forward  these  flxcts  in  explanation  of 
the  development  of  white  thrombi.     So  lon'r  as  the  cir- 

n"e  uTto  "'■"  T  "^^'^"^^  '"'-""^^■"  central.-and  adh  re 
o  '  n  c  i;;'  "h  ""  '".^'^^  '-''''^  ^^^"  =  ^-'  -hen. 
ion  f  the  corpuscles  ,s  disturbed,  and  the  plaques  end 
to  collect  at  the  periphery,  and  aggregate  in  grupsal 
any  point  which  has  been  injured,  or  which  h.as  b L' 
deprived  of  the  endothelium.  Slowing  of  the  b  oo 
stream  ,s  then  on  this  view,  one  of  the  essentials  i  the 
formation  of  white  thrombi,  and  this  is  entirely  in Vcco  d 

his  i:ot  \ir  T'  °'^'^  P^^'hology  of  these'structiS 
It  is  not  alone  the  presence  of  intact  endothelium  which 
prevents  the  formation  of  tarombi  in  the  vessel     tb    we 
frequently  hnd  in  aneurisms,  on  the  hear   va  ve    Vr^d 

z^^-Tn:!:'r'''  r\  ^°"^'^  ^^^■"-  "p- '^'-h 

o  1  d  on  nH  ■      ^"'^'''^  ^'^'■°'"'^'  "'^  "°t  Often 

found   on  atheromatous   ;ilcers.  which  would  offer  the 

avorable  localities  for  their  formation  if  it  is  the  ei  it  e 
hum  alone  which  prevents  it.  The  other  condition 
wouia  appear  to  be  slowing  of  the  blood  stream,  wh 
and    7^'^^^".'^"^;-"  '«  P'ay  such  an  important  part 

Sht  of'tle"  ^1^^""^-"--  °f  -hich  is  wel'seen  in  tl  e 
light  of  these  observations  of  Eberth 

What  I  contend  is.  that  the  white 'thrombi  are  com- 
posed chiefly  of  plaques,  and   that  the  colodess  cor- 
pusclcs    play  an   altogether  insignificant  part    n   the  r 
S'-olfcled"    T  ^^P^"'"-''^'  -'dence  which  h! 
morbid  an:fomy.'""^   ""   ^°-"P'^'^'>'  '^>'  ^   ^'"'^X  ^^ 

The   further   development   of  the   thrombus   results 
from  the  disintegration  of  the  plaques,  and  the  LrTna! 


I  • 

i 


n 


i 


^4'/ 


r 
) 
) 
1 

i' 


(•'■ 


I 


:■  'Im 

1      I 

! 


Uta^li^H   d  .31*11,... 


4;   .; 

,!  .i'i    ■  '     , 

li 

«■} 

u 

H 

^m 

I^S 

■  1 

H 

IB 

■ 

54 


OSI.KR, 


tion  of  a  finely  j^^ranular  material  in  which  there  may 
be  no  fibrin  filaments.  We  must  recognize  a  granular 
or  stroma  fibrin,  as  Landois  call  it,  and  a  fibrillar  or 
plasma  fibrin.  The  former  is  a  granular  material  which 
develops  when  cells  undergo  the  peculiar  metamorphosis 
described  by  Weigert  as  coagulation-necrosis,  and  it  is 
this  in  reality  which  goes  on  in  the  white  thrombi. 
There  may  be  no  trace  of  fibrin  filaments,  but  the  chief 
mass  is  made  up  of  a  granular  matrix  in  which  the  out- 
lines of  the  plaques  are  no  longer  v-isible.  The  stages 
of  this  transformation  I  have  traced  in  thrombi  of  the 
femoral  vein,  and  it  is  well  seen  in  passing  from  the 
superficial  parts  to  the  deeper  parts.  The  plaques  on 
the  surface  of  a  while  thrombus,  as  at  Fig.  5,  may  be 
intact,  or  they  may  show  signs  of  disintegration  and 
conversion  into  a  granular  debris.  The  central  soften- 
ing of  a  while  thrombus  results  from  the  liquefaction  of 
the  plaques,  and  is  a  result  possibly  of  the  presence  of 
fluid  in  greater  abundance  than  is  necessary  for  the 
process  of  coagulation-necrosis.  (2uite  recently  in  a 
case  of  typhoid  fever,  I  had  an  oi)porlunity  of  studying 
the  histological  characters  in  thrombi  in  the  femoral 
veins.  In  both  they  were  mural,  and  had  originated 
behind  the  valves.  The  attached  portion  was  a  light 
brown-red  color,  but  the  upper  half  was  of  a  dead-white 
color,  and  the  extension  into  the  iliac  was  of  the  same 
character.  The  line  of  demarcation  between  the  two 
parts  was  pretty  clearly  defined.  At  the  thickest  portion 
the  superficial  while  thrombus  had  softened  to  an  opac[ue 
milky  liquid,  but  at  the  prolongation  it  was  firm  and 
consistent.  A  few  colored  and  colorless  corpuscles  were 
scattered  through  the  white  thrombus,  but  the  great  mass 
of  it  was  'omposed  of  blood  plaques,  and  a  study  of  the 
softened  milky  region  showed  clearly  that  the  granular 
detritus  was  composed  of  the  altered  plaques.  In  the 
deeper  parts  the  plaques  became  less  and  less  distinct, 
until  a  point  was  reached  ii  which  the  individual  cells 
were  no  longer  visible,  and  tliere  was  nothing  but  an 
indift'erent  inatrix.  The  contrast  in  color  between  the 
outer  and  inner  portions  indicated  a  difference  in  age, 
possibly  in  mode  of  formation,  lliough  in  the  outer  por- 
tion of  the  brown  and  the  inner  i)art  of  the  white,  close  to 
the  line  of  demarcation,  the  structure  seemed  identical. 
In  the  light  of  these  new  observations  on  the  connection 


1 


■  if 


;         1 


-v^be'ttiSi'is;:;;!'  'r-''  "^^  ^"^'-  ^i--- 

tio"  of  the         e     ■      n       II  ^''-■'  ''''^''"^"'•'^•■'y  the  rela- 

statements  here  made  rc/m  ,  , ,  ^'^  "'^  t--^"!^  ^^  the 
plaques  with  thrombos''  S  u::rr''°"  ^'^ 
observation  on  the  strucne  of  fh  ?    ?"'   ''"■"'^"' 

j^a.h..mato„s.eers.^:;r:,;j:^j:^r';;;^n^ 

'■^lobular  vSa  un'^of  "P'""'^."r>-  "^  examining  a 
venture  to  s  a t e  t  "  .h/v""  '"'"''  "■■  ^•'^""■'<^'<=-  '-'^  I 
similar  struares  '  "'  ""'"P"^^^  ""^''"-"r  of 


!         3 


1    .*'         i'     • 


■il;i   I 


J 


■    J 


ft  ^^ 


:| 


>i 

!  nm 

'■ 

" '  ii  i'l 

1 

b 

1 

;/ 


^   ,-h 


vir 


? 


'I    Hi     !■ 


BICl 


l^yxn 


1 


THE 


BICUSPID  COiNDITION  OF  THE  AORTIC  VALVES. 


■.-    \: 


I  f 


BY 


VVILLIAM  OSLER,  M.D.,  F.R.C.P.  Lond 


1 1 


REPRINTED   FROM   THE 
TRANSACTIONS   OF    THE   ASSOCIATION 


OF   AMERICAN   PHYSICIANS, 

JUNE  18,  1886. 


11 


>       ■-!    i 


PHILADELPHIA: 

WM.  J.  DORNAN,  PRINTER. 

1886. 


M 


II- 

I    J 

#  ■    1 

■  ■  !  i   ^  ' 

h  If* 


i   I 


THE  BICUSPID  CONDITION  OF  THE  AORTIC  VALVES. 

Ilv  WILLIAM  OSLEI!,  M.D.,  F.llC.P.  1,„„. 

rwvan.,!^   ^^  ,. _  * 


I-ROFESSOB  OF  CLIMCAI,  MKDIO 


INE  IN   IIIK  I'MVElisriY  ,„•  rEXN.yi.vAxi 


Def,n.,t„«._A  ,,„umi„„  of  ,1,0  arlori,,!  vaivo,  in  ,vl,iol,  „v„  of 
1^   ,,«,«  a.,  „..„.c.  or  10.,  porifcotl,  f„sod,  ,0  tl,a.  .he  orifico  b  JZ°i 

by  only  two  segments.  to^aiuLu 

common  al,„„„„„li,y,  „„,,  i,ilg.  1,,,,  „,„„,„„,  e/casos        ,  o  ll 

»  ■;oco,„ ly    .00,,  „„„,„  bj,  Mar.i„o..i  „,„,  Spornio^  an,I  ,  !    "w 

m  tho  aort^  ,„lvo  ,n,j;l,t  I,o  gi-oally  oxton,W.  I„  „vo,-  oi,.l,t  l.un.lrcj 
,™iops.o.,,  I  ,„vo  „,ot  with  it  io  LS  oaso.,,  17  i„  ,l,o  ao.tic'val  ^  „1 
n  1  ca.0  m  boH,  aoH.o  a„,l  p„l,„o„„,y  valves.    A  .letailed  aceo,  „   „ 

<li*  se  of  .  11  k,„,l,,,  ,l,o,-o  ,vo,-o  ;,-  i„  wl.iol,  (ho  .aortic  .segment,  ,vero 

valies,  so  that  this  eo,„l,t,„„  „,,s  pres,.„t  in  over  thirty  nor  cent  of 

aff™.«l'"7n'r:f ';;"  ]t:^"'-^^°  »™-/  -«»-t3  are  usuallv 
■thUtd.     In  10  of  the  18  eases  this  ws  the  onler,  and  it  may  -ilso 
have  been  so  ,n  Ca»e  VII.,  .,„t  I  have  no  note  of  the  L"  'n 
po.nt    previously  overlooho,!,  ,„ay  prove  of  in.c-cst  in  the      i„l  ,  7 
»"''  ^''""'''  1"=  "'■"«'">•  "otod   n,   f„„,re  observations.     The  undeti 

•  Viivhow's  Archiv,  xci.  s  \Hi,l  .11.,  r.    »      .      ■ 

a  ,;„,,etu  ,!oll,,  riin|,,,„._  ,S8G   r,.„rint  "'"  "'  '*''"''''''""  '"  '^"^'"°'  '^Sl,  reprint. 

Tl.i.  "hviatc.  Iho  o„Mf„«i„„  which  at  ,  r^on    r™    tffr     ,"  '     "^         "  ""'"« '•""-'  "■«  ""-•coronary. 
P.-Hor  an,,  one  anterior  ..,,  a.„.  h^.tr  .^r.:;:;  ■  ^'I.ir^^C;: .Sr"'^  """°""^'^  "^  '-^' 


^:'! 

Vi 

Ml;: 

1  M"! 

i 

lii 

i 

III 

mt  1 

III 

ii.  " 

■  II 

ff  H 

'    iH 

Ki^  3 

1  H 

Sf' •' 

1   11 

r  ' 

III 

i'- 

T   "W 

• 

i  ill  ■ 

!'■ 

2  O.SLKK, 

ciisjis  may  liiivc  :i  itorfectly  iioniial  appearance  (Cases  7  and  10), 
but  in  tuliilts  tlioy  are  almost  invariably  tliickened  and  tbe  seat  (if 
sclerotic  or,  in  some  cases,  ulcerative  cluuiges.  In  Case  7,  a  fa'tus  of 
seven  montlis,  tbe  tissue  of  tbe  valves  sbowed  no  trace  of  tbickeniiig 
or  inflammatory  processes.  In  Case  10  tbe  united  segments  were 
practically  bealtby  ;  in  tbe  otbers  tbere  were  sclerotic  cbanges  more 
or  less  marked,  and  in  several  distinct  losses  of  substance.  Unless 
seriously  stiffened,  or  tbe  seat  of  erosion,  tbe  bicuspid  segments  seemed 
capable  of  closing  tbe  aortic  orifice,  and  in  several  instances  tbe  valves 
held  water  wben  poured  into  tbe  aorta.  In  13  cases  tbe  valves  were 
carefully  measured.  For  piir})oses  of  accurate  comparison,  G  of  tliesr 
may  be  excluded  on  account  of  incompleteivess  or  extensive  disease  of 
one  cusp.  Of  tbe  7  cases,  in  1  tbe  two  cusps  wore  of  ecjual  size,  in 
2  tbe  single  curtain  was  tbe  larger,  while  in  4  tbe  fused  segments  were 
larger  than  the  single  one.  Tbe  average  measurement  along  tbe  free 
margin  in  these  7  cases  gave  for  tlie  fused  cusp  3.93  centimetres,  and 
for  the  single  cusp  3.4")  centimetres,  so  that  the  former  was,  as  a  rule, 
larser  than  tbe  latter. 

In  tbe  conjoint  valve  tbere  are  three  points  to  be  noted.  Tbe  free 
border  was  usually  straight,  oftentimes  curled,  and  in  no  instance  was 
there  any  nodular  thickening  indicative  of  the  presence  of  a  corpus 
Arantii.  The  attached  boi  ler  i>resented,  from  the  ventricular  aspect, 
either  the  nonnal  contour  of  a  ,  cmilunar  valve,  or,  more  commonly, 
a  shallow  groove,  indicative  of  tbe  junction  of  two  cusps.  Tbe  aortic 
side  of  the  valve  presentetl  in  all  tbe  cases  a  more  or  less  distinct 
raphe,  or  fntnum,  dividing,  or  indicating  a  division  into,  two  sinuses. 
This  raphe,  tbe  representative  of  tbe  bands  which  in  tbe  nornial 
segments  unite  them  to  the  aortic  wall,  was  present  either  (a)  as  a 
narrow  elevated  ridge  confined  to  tlie  aortic  Avail ;  {b)  as  a  sini^lc 
band  passing  for  a  variable  distance  on  to  the  valve;  or  (c)  wiis 
divided  into  two  distinct  portions,  which  passed  out  the  inner  aspect 
of  tbe  valve  and  were  ultimately  lost.  The  sinuses  of  Valsalva,  thus 
incompletely  marked,  were  usually  of  eipud  size,  and  in  sixteen  of 
tbe  cases  they  gave  origin  to  the  coronary  arteries. 

Of  associated  lesions  in  this  condition  of  tbe  valves,  hypertrophy  of 
tlie  left  ventricle  is  llie  most  important.  This  existed  in  a  majority  of 
the  cases.  In  Xos.  10  and  14  it  was  scarcely  noticeable.  The  stale 
of  the  other  organs,  when  of  interest,  is  mentioned  in  the  tables. 


7  and  10), 
the  scat  of 
r,  a  fo'tus  of 
F  thickfiiim^ 
;nients  were 
langes  more 
iCC.  Unless 
lents  soeiiieil 
cs the  valves 
'  valves  woi'c 
1,  G  of  tlie.se 
ve  disease  of 
|ual  size,  in 
gnients  were 
long  the  free 
:imetvcs,  and 
IS,  as  a  rule, 

I.  The  free 
instance  was 

of  a  eor[ius 

cular  aspect, 

e  commonly, 

Tlic  aortic 

less  distinct 

two  sinuses. 

the  normal 
her  [a)  as  a 

as  a  sinii'Io 
;  or  (c)  was 
inner  aspect 
alsalva,  thus 
n  sixteen  of 

pcrtrophy  of 
a  majority  of 
:.  The  stale 
3  tables. 


BICUSPID    CO.VI.TTIOX    OF    T.rr     . 

01.     Tin,    AORTIC    VALVES  <? 

CLi.vrcAi-  Fi'rrriMN--. 

dition  was  found  afWdJath'ndth'r   ""  "^"^  ^^  =""'   ^'^  ^'-  con- 
ha.l  summed  from  cardia^t^  TlT  "^^'T:  ''''  "'"  ^— 

-'  'n  Case  4  death  was  alL  llZ  b^  :.;;;';V''  'f  ^'"'''-'^y' 
a  cerebral    aneurism.     E,,,,„,i„.     ,,;' I'^'^-'^f/'-""^  the  rupture  of 
t^velve   cases    presented   the   clinh-d    f    .      "     f' "'    ^'"    '•«>"aining 
7"t  there  was  ulcerative  ;:;::,^'':-;^  '-';;   '''--.     I^ 
0     a  verv    severe    typo.     Cases  1  '     -    ^"T,  !'   "'   ^'^'  '^"J  18 

"*    .^-lual    heart    failure   with    t h'o      '„     '  '"'•'"    ""'^    --"'l'>- 
compensation.     Thus    ir,    fiHeon'    /f  ^^^'"P^oms    of   disturbed 

eould    be  attributed    direetlv  or    inihr  .VTt^    '•'""   ''  ^^"^^'' 
anomaly.     Whether    the  rjs.dfc  of       ,  ,  '  existence  of  this 

^.ii- in  development.  the'::;nt^,  r;:;';^^        ^  '^  P'-^n^^^ 
''«  '"Story  of  aortic  valve  disease      The    ^  ^    ■        ""''^^''^'"^^  P'^''^  in 
tonned  structures  to  disease  is  well  J-.,  ''T''',    I^''""*'"^'«  of  maU 

;'-  --ely,  in  the  adult,  f^^J  f^f  ^W  "T    '"  ^"''"'"^  ^^^'''^^^ 

'^'fofmycases  there  wis  atoZnt^'^j'Tf'  1"^  '"  '^^^^^^ 
tJ'c  fused  curtains  is  more  severe  ^^'^-'^tloss,  the  strain  upon 

'»  the  f<etus,  and  even  i,  ,".;'""  '''"'f  -«P«'  ""^  though 

t'-  -tnnd  thinness  and  ,m    i,   ^  ^ef  !     "V  '"  ^'^^'^^  "'^^^  ^"- 
•■""'  ti'ickening.     I  ],,,,  ,,,;',;'  r^'J^'^,  '  '^^''  ^here  are  induration 

with  which  ul^erativ  ^;  :'^  :  ^  '^  '"T"'"  ''  ^''^  ^^I-"^^ 
^^  '«  -eeptional  fl>.  no,t  t  .^  t  f'^''^^^  ^f ^^^^  ^'"^-^ 
investigations  in  experimenfd  em  r.  ,  '  ^''^"-'''''-  '^^'^  '^'^^^ 
«™od  by  the  beauLl"^^,  ::     r^  l^^  are  con- 

woid.lin.licatethatthemicrocTc     '  7r''''"  '"'  '^"'  '"^^ting) 

^'•^theslightestabrasi    "^C::Z     ?  f-"'  '"  -™=^^  val^ 
i^ibbertM.as  been  able  to   n    ,  ■<  en  r       '"" '"''■'"^^'^-  ^^^^'^«»gh 

the  n.icroo,^anisn,s  w  t  o  t"  T  T  '•'  '^^^^'"^  -'^"^^f 
'-^-^y  i^  the  material  1:1  Zo^ZtZ  f  '''  "''''''  ^-'- 
'•ecent  experiments  support  th.  1  ='"'  P'-^^'ti^'cs,  these 

tl'at  a  damaged  valve  if^      n   s  Trf  f  '"  ^"^■"^^^•^^  -- 
ative  changel  '^  '''"''^^  ^'^  ^''''^'^  the  seat  of  ulcer- 


■■isonably  be  iussnciatea  with 


iiiiglit  1 
=  British  Meili'cal  J.ni'rnai.' 
'  Tagolihut  tier  58  V 


^  valve  loHion. 
Culstoiiiaii  Lectures,  188".,  vol.  i. 


previuiia  eiiihuljc  proc, 


's--*,  which 


-.Co  .^.^v::;— - -r-- f-.-.-er  ..-strath 


ft,  1885,  No.  42. 


Ijurg,  1885. 


i  >l 


^i    '  ■ 


OSIiER, 


f      ; 


*  t 


I  ! 


Of  tho  cif^litoen  casos  lioro  roporttMl,  all  snvo  one  were  in  iidultn. 
In  Diljf's  tablt"  of  twcuty-tlirco  ciiscs  tlic  iigo!-  of  nineteen  are  ;.;iven, 
and  uf  these  only  nine  -wore  adults.  Seven  wer"  under  five  years  of 
age.  My  experience  has  licrn  in  a  general  hospital  in  wliieh  the 
great  majority  of  the  patients  were  adults,  Dilg's  paper  is  on  various 
cardiac  anomalies,  so  that  his  search  in  the  lilcraturc  has  tended  in 
the  direction  of  paediatrics,  which  may  account  for  the  large  number 
of  children  in  his  list. 

OiutiiN. — Whether  the  condition  is  the  result  of  a  foetal  endocar- 
ditis or  is  an  anomaly  of  development  cannot  be  finally  settled  until 
we  have  fidler  knowledge  of  the  details  of  formation  of  the  svuiihniar 
valves.  The  advocates  of  the  inllammatory  view  urge  that  indications 
of  the  original  separation  invariably  exist  and  that  the  valves  as  con- 
stantly present  evidences  of  endocarditis.  'I'o  this  view  A'irchow  has 
given  the  weight  of  his  authority  and  has  recently'  stated  that  an 
examination  of  the  (piestion  has  convinced  him  that  a  majority  of  the 
cases  show  signs  of  a  "  secondary  fusi(m  of  two  cusps."  This  cer- 
tainly may  be  so  in  some  cases,  but  the  following  considerations  lead, 
I  think,  to  the  conclusion  that  in  many  there  is  a  faulty  arrange- 
ment at  the  time  of  the  development  of  the  segnrents. 

First.  The  greater  frequency  of  the  anomaly  !it  the  pulmonary 
orifice  and  its  association  with  other  cardiac  defects.  In  the  sixty-four 
cases  collected  by  Uilg-  there  Avere  fifty  with  imperforate  ventricular 
septum.  Errors  of  development  occur  more  frecpiently  in  the  right 
heart  and  involve  the  pulmonary  artery  more  often  than  the  aorta. 
Foetal  endocarditis,  however,  shows  the  same  preference,  and  un- 
doubtedly plays  a  part  in  the  pi'oduction  of  stenosis  of  the  pulmonary 
orifice  and  nari'owing  of  the  conus.  So  far  as  we  know,  the  develop- 
ment of  the  segments  occurs  at  a  very  early  period,  eighth  to  tenth 
week,  and  it  is  really  difficult  to  conceive  of  an  inflammatory  process 
so  extrenaely  limited,  in  an  embryo  not  more  than  a  few  millimetres  in 
length. 

Second.  A  careful  study  of  the  united  valves  throws  light  on  the 
question. 

(a)  In  Case  7,  a  foetus  at  the  eighth  month,  the  curtains  at  both 
arteries  were  involved,  but  the  conjoint  cusps  were  natural  in  appuur- 


1  Virchow'fl  Archiv,  Bd.  103. 


'  Loc.  cit. 


I 


BlOUsni,   c.,X,„TIO.V   OP   THE    AORTIC   VAI.VKa.         6 

»n™  a„,l  wi,l„„„  .  „,.co  „(■  i„ll.,„„„„„,    ,,„„  (,„ 

»,.™,l  „,.o.. .,„  ,„  ,,      „,„„,„„ _„,  ,^,,  _,;.^  __^^  J^ZZ 

lo,  ..  ,s  .,„■„.! V  c,,uoo,v„l,lc.,  if  ,l„.  |-„.i„„  „,„  i„||,,,„,„„„„.,,  „„."„,„ 

V.  «.     In  <lm  t,,.„  .™o,  the  ..wra.o  length  „f  ,1„,  ,i„j,|„  ,,„„,„^„, 

even  „t  these  free  l,„n,  „ken.ti„n  ,„„l  eireum»t„n,.os  interfering,  «ith 

the  .«;cnniey  of  the  meawrement,  the  fi-nrcs  wer,.  -  !-  '  "'"' 

f-  .ho  single  .,„  ;3.9S  ee„.i,„etr;  for  tir^:;   ^    ^  ^T^Z 

he  ensps  were  „    e,,,„.l  .,i.o  a„,l  in  ,„„   i„»t„neos  th     si,„  le       r    L 

r:;:::;retr';:':i:;^:;rs::r^™'''r "^-^"*" 

'-'^r'l' «-*■«-'•■«"-■';  rrritirn'':;:: 

';'",     "  "'*;■.  '  """!'•  »»Hi.lorably  larger  than  „,„al.  *■ 

(•■)   I  he  eon,l,t,o„  of  the  vontrienkr  face  of  tho  fnse,l  segment  in 
sen  ,roo    r„„.  nieeration  or  exlreme  in.lnration,  seen,,    Zr2LZ 

1  ..ce  of  the  oxtenstve  t.ssno  changes  whieh  n,„st  take  ph.ee  in  the 

process  of  union  of  two  cusm      Tl„>  d;   i^-    i     .    •  i"'i^^  J"  me 

,t  tl.o  .,H,  111       ""/^"*^P-^-     -I'lo  slight  indentation  usually  present 
a   tl.e  attaclH-d  honlcr  has  been,  in  most  of  my  cases,  without  a  trice 

".  tUj    btlow  .t.     If  we  consuler  the  extent  of  the  space  existing 
oU-;  two  segments  and  the  nature  of  the  endocardia      1^    ef 
1  .cl.  cause  curling   shortening,  or  other  deforiuity  of  the  se.„  c^t 
t    .almost  unpos.ble  to  suppose  that  a  fusion,  caused  in  thfs  Z 
C....1..  leave  the  ventricular   fi.e  of  tho  valve  smooth  and  tt:i 

T/iM    A  staily  of  other  an..malies  of  the  valves  has  an  im„„,.(,„, 
l;.-..>g  on  tho  suhjeet.     VVithont  any  fusion  of  the  c„s       Z 

""'u:::;;:™''"'" ";  "-'r'  -*  -^  -tachmenti'.;,::.^ 

an  IdistinT  Int    ,  7"       ""    ""™'  "'  ™'=''  ""^  ■'■=""''-  ^OP-"' 
anil  aistina,  hnt  the  tivo  may  join  at  a  lower  level  and  at  an  anterior 

n  most  of   hese  cases  that  the  anomaly  is  the  result  of  a  innetion  .^f 
t>.ofrc=  herders  of  the  cusp,  from  four  to  tive  centimetres  of  tlXa;; 


(i  ■  i     I'-i  > '  i 


<;;!     • 


■■  ^• 


6 


OSLER, 


furthest  from  the  corpua  Arnntii.  The  condition  is  not  very  unconinidii. 
In  a  recent  sjiceinicn  two  of  tlie  aortic  valves  hml  pfii'tiiilly  united  and 
were  a  gootl  (U'ai  tiiickened.  They  wore  united  to  the  aorta  hy  a 
median  raphe,  siniihir  to  that  no  often  seen  in  the  conjoint  valves,  but 
in  adilition  there  were  three  strong  ehonhvj  tendineic,  seven  millimetres 
in  length,  which  united  the  ed;i:;e  of  the  valve  to  the  aorta,  to  which  they 
were  attached  at  the  noruial  level.  TImSO  cords  were  thin  and  free 
from  any  trace  of  intlamniatory  thickening.  The  condition  was  un- 
questiunaldy  a  defect  in  development  and  was  of  a  similar  character, 
though  not  so  e.vtensive,  as  that  under  consideration. 

Fourth.  W  it  turns  out  to  be  correct,  as  my  cases  indicate,  that 
the  affected  valves  are  usually  those  Iiehind  which  the  coronary  arteries 
are  given  off,  this  would  point  to  some  error  associated  especially  with 
the  developnu'iit  of  these  cusps.  It  would  appear  from  the  ohsiTva- 
tions  of  Tonge,'  that  two  of  the  segments  arc  formed  before  the  divisiuii 
of  the  primitive  trunaus  arterioaus  is  complete,  while  the  third  arises 
latci-  after  the  pulmonary  artery  and  the  aorta  have  divided.  It  is 
•not  at  all  improbable  that  we  may  have  here  a  clew  to  an  explanation 
of  this  anomaly,  but  this  is  conjectural  until  we  have  I'ldler  details  of 
the  process  of  the  development  of  the  sigmoid  valves  in  mammals. 

J  ProcoeJ^"      jf  Royal  Socii'ty,  1808,  xvi. 


1 


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BICUSPIP    CONDITION    OF    THE    AORTIC    VALVES. 


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ON  THE  USE  OF  ARSENIC 


IN 


CERTAIN   FORMS  OF  ANEMIA. 


N  an  address  last  year,  Dr.  Wilks  remarked 
1  that  in  therapeutics  we  do  not  so  much 
need  new  remedies  as  a  fuller  knowledge  of 
when  and  how  to  use  the  old  ones.     I  do  not 

.sTo^n'  ''''''"^  "'"^^^^^'°"  °f  ^h'«  than 
IS  afforded  by  arsenic,  a  good  old  remedy,  for 

cases  oT  '"""'•  "'"  "^  ""^^  -^"-^  -  -«ain 
cases  of  pernicious  anaemia.     The  attention 

of  the  profession  was  directed  to  the  subject 

reCr       '"   ''^^'  "^'^  '-''^'^""^h  ^-"-« 
reports  bearing  witness  to  the  value  of  this 

c'rug  have  appeared  from  time  to  time,  the 
knowledge  of  its  efTicacy  does  not  appear  to 
be  very  wide-spread,  and  there  are  still  points 
in  connection  with  its  employment  upon  which 
we  need  information.  These.  I  trust,  disc  s- 
s.on  may  bring  out,  and  render  clear  the  di- 
rection which  future  observation  should  take. 


I' 

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In  treating  a  case  of  anaemia,  it  is  of  the 
first  importance  to  ascertain,  if  possible,  the 
cause.  For  convenience,  and  until  the  pres- 
ent complex  pathology  is  simplified,  we  may 
classify  the  ancemias  into  secot.dary  and  pri- 
mary ;  the  former  induced  by  causes  acting 
upon  the  blood  itself,  the  latter  the  result  of 
disturbance  in  the  blood-making  organs.  This 
distinction,  not  always  clear,  serves  to  sepa- 
rate two  clinical  and  pathological  groups  of 
cases. 

The  secondary  anaemias  are  the  most  com- 
mon, and  arise  from  a  variety  of  causes,  as 
hemorrhage,  prolonged  drain  of  albuminous 
material  in  chronic  disease,  and  the  action  of 
toxic  agents  on  the  b'ood.  In  very  many  of 
these  conditions  a  return  to  the  normal  state 
follows  naturally  upon  removal  of  the  cause, 
and  the  regeneratio;  .jf  the  corpuscles  may 
take  place  with  exi  '.ordinary  rapidity,  as 
after  a  copious  ble^  uing  or  a  sharp  fever  ; 
but,  as  a  rule,  iron  in  some  form  will  be 
found  useful  or  indispensable.  In  three  of 
these  secondary  anaemias  I  have  found  arse- 
nic very  beneficial. 

I.  The  Ancemia  of  Heart- Disease.  —  In 
chronic  valvular  trouble  we  not  infrequently 
meet  with  an  impoverished  condition  of  the 
blood,  which  materially  aggravates  the  car- 
diac distress.  The  comfort  of  such  patients 
is  in  direct  proportion  to  their  corpuscular 
richness,  and  without  any  apparent  increase 
in  the  valve  mischief,  '  duction  in  the 
ratio  of  the  corpuscle.'  •  lowed  by  short- 
ness of  breath,  palpuati'— .,  and  signs  of 
heart-failure.  The  vai>.  of  iron  in  this  con- 
dition   is  well   known,  and    its  combination 


with  digitalis  a  universal   practice.    Arsenic 

»  criudren,  or  if,  as  sometimes  happens  iron 
does  not  agree.     ,„  m„e  of  this  ^   aw 

va    e;d  ,ea«  for  r'"'  '''"'   '""   "'"'  "^^'-^ 
aisease  for  four  vears.     He  had   h^^„ 

wmtenn,  in  the  South,"  and  went  a  terwa  d 

him     he        ""'  ""^  ■''"'"^■^-     ^^'hen  Tsaw 
n'm    the   an.tmia  was  very  marked    pn.i  t 

.u«.red  fro.  „reat,„ess„eL  ^te  si^^ 

exertion.     1  here  was  no  cardiac  distress  an-' 

aZT:T-''  T  not  seriously  dist:,;bed. 
felr  f  t^T^'  ^^  ^"^  ■'^^^'^'■^1  chills,  with 

fever,  for  wh.ch  he  had  taken  quinine      He 
was  ordered  Fowler's  solution  o/  arsenic  ^e 

g>nnmgwithn,iii,threetimesadayand?n 
creasmg  to  n,  yi,  if  ^ell  borne.     He  had  bee: 

akjng  an  iron  and    strychnine   pi,,  for  ,:,- 
era!    weeks,    and    had    with    him    a    boxful 
which    he  was   advised    ^o    finish.     dS' 

wasprescnbed.butw...ottobetake'n'^^^^ 
iess  there  were  signs  of   heart-faiJure      The 
d.et  was  carefully  regulated.     The   lad   im 
proved  rapidly,  and  within  six  week     had  a' 

Tweig^  rh'd'^  ^^'"^^  -erlfpo'ut: 
n  weight.     He,iad  not  needed  the  digitalis 

ment "hid"  ""•"'"  '^°"'^-     ^'^  ™Pro  e' 
ment    had    continued    on    the    3d    of    thi. 

t:r.\u;"'"^  here  there  was'l  mLa  " 
tamt     but,  in  any  case,  if  medicinal  agents 
had  anything  to  do  wuh  the  rapid  impSy 

s^oSon'.'^   "^"^    '^    ^"^    -    ^'^   F-ierl 

arsenf  -ft"'"^  ^^'^ma.-The  yalue    of 
arsenic  m  chronic  ague-poisoning  is  so  wel 
recog„,,ed  that  I  need  scarcely 'deLn  ;" 
with  the  narration  of  cases  in  support.     There 


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have  been  several  at  my  clinic  during  the  pa.'." 
year  in  which  the  Irnproveuient  in  the  blood 
condition,  •>  tested  by  the  hacmacytometer, 
has  been  v.'  y  remaricable.  One  case  in  par- 
ticular, from  Cape  May,  T  may  refer  to,  as  the 
p?,<:!ent,  with  onla<  ged  .-^pleon,  had  on  two  oc- 
casions hemorrha>',e  frcim  the  stonu-ch.  I'he 
arsenic  in  this  case  v.as  pu^h(;d  for  several 
months  in  increasiiig  doses.  At  one  time  he 
took  TTijxxxvi  of  the  Fowler's  solution  daily. 
When  last  heard  from,  in  July,  he  was  at 
work,  and  had  gainc:  in  flesh  and  strength. 
On  May  12,  the  date  if  the  last  blood  count, 
the  percentage  was  over  eighty  (it  had  been 
scarcely  fifty),  and  the.  -pleen  had  diminished 
materially  in  volume.  Jn  certain  of  these 
cases  the  ratio  of  the  corpuscles  may  increase 
rapidly  without  any  essential  change  in  the 
volume  of  the  spleen.  In  the  case  of  M.  D., 
a  girl  of  15,  \vho  has  been  in  the  University 
Hospital  on  several  occasions  for  the  past  two 
years,  the  arsenic,  which  was  very  persistently 
employed,  does  not  appear  to  have  reduced 
the  spleen  in  the  slightest  degree,  and  yet 
under  its  use  the  corpuscles  rose  to  eighty-five 
per  cent.  In  this  instance,  with  a  history  of 
malaria,  there  is  evidence  also  of  congenital 
syphilis,  to  which  m.ay  possibly  be  due  the 
splenic  enlargement.  Injections  of  arsenic 
into  the  substance  of  the  organ  were  tried 
without  benefit. 

3.  Certain  Ancemias  of  Gastric  Origin. — As 
a  tonic  in  debilitated  states  of  the  stomach, 
arsenic  has  long  been  c  fnvorite  remedy  with 
many  practitioners.     1  .ometimes  also  of 

great  service  \v  the    .      mia  of  chronic  gas- 
tric catarrh,  part  •.  ..    ,  in  alcoholic  patients. 


V 


G     ao-Pri  „.  /  ""'^P'tal  this  spniisr.     \v 

April  5  with  an.^mia  and  aua  'ks  of     •' m' 
"ess.     Ill   for  ten    davs  •    v  ^"^'''■ 

stomach,  and  fai    in,    ;;i,::;;:':;';^'  '""    ''" 
stand.     Hadbeenfaniri^s     :?^^^^^^ 
time  and  p-ettino-  ,.oi         ''^^^ength  for  some 
palpitation'        i",,  ."[f  ^"""^^^   fron, 
He  was  profound,    a„L„      Z""'  n  °""- 

coated  :  g„a.  irritaf,",;  „"!"?,„    '■°"«- 
'ng  on  the  s!ip-liff.cf  ,.  S'tomacn  ;  vomit- 

bin.  of  :£■  ,i?rr":?;  rr^r" 

rest,  given  a  miik  diet  and  P.  ,  f  ""'''  ""^ 
in  3-drop  doses.  Th^  ",/.', '°'"''°" 
not  more  than  twenty  five  1  ''"'"''  ''''' 
coloring  matter  Tnt  \lr:,r''Th'  ■'' 
provement  was   ran.rl    .n  .    f      ?"     ^^^  ""' 

corpuscles  had%;r.'orer'?;nt\:"'  "•= 

J;ad„ai„i^^.eTs:r.r;;:,f.''rTr^d"^ 

had   been  at   w°  k      p"/',"? " /'•'P'"  ■  ■  •"" 

•here  was  „,ce    "*;  of  Xf'  '"  .l".'''  '''''■ 

tion  ,„  the  chroni     cata  rl,    Tf  ^  ',"  '■""'''■ 

theco„di,i„„.i,„„j;„='Y:    .,ieT;j''«"" 

seemed  to  be  highly  benefcill  and  a,  h""" 
ceived  no  othpr  m^,!-      •  '  ^^  he  re- 

ably  att*„eo"f  ';:":"•  '''  -^  --- 

It   the   stimulation  of  the 


>  * 


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blood-making  function.  As  we  shall  see, 
there  are  ancEmias  of  gastric  origin  in  which 
this  drug  is  powerless.  These  are  some  of 
the  secondary  anannias  which  have,  in  my 
experience,  been  apparently  benefited  by  the 
use  of  arsenic. 

Turning  now  to  the  primary  group,  we  have 
here  again  for  convenience  to  make  a  division 
of  the  cases.  There  is,  first,  a  large  section 
of  what  may  be  called  cytogenic  an;tmias, 
in  which  the  reduction  and  alteration  in  the 
corpuscles  is  associated  with  evident  changes 
in  the  hasmatogenous  tissues. — the  spleen, 
lymph-glands,  and  bone  marrow.  Sometimes 
these  changes  are  accompanied  by  an  increase 
in  the  colorless  corpuscles  of  the  blood  ;  and, 
depending  on  the  organ  involved,  we  then 
speak  of  splenic,  lymphatic,  or  medullary  leu- 
kaemia. If  there  is  no  marked  increase  in 
the  white  corpuscles  we  call  the  cases  splenic 
an?emia,  lymphatic  an;«mia  (Hodgkin's  dis- 
ease), and  medullary  anaemia.  The  pro- 
nounced leucocytosis  in  cenam  of  the  cases, 
which  gives  a  special  character  to  the  blood,  is 
probably  not  such  an  important  factor  as  we 
have  hitherto  supposed,  and  there  are  such 
insensible  gradations  between  the  cases  that  in 
a  strict  classification  they  may  be  appropri- 
ately grouped  together.  Secondly,  there  is 
the  curious  primary  ana;mia  known  as  chlo- 
rosis, characterized  by  '.veil-marked  etiologi- 
cal and  anatomical  peculiarities  ;  and,  thirdly, 
we  have  the  much-discussed  affection,  perni- 
cious or  essential  anaemia. 

The  anaemias  of  this  primary  group  offer  a 
remarkable  therapeutic  study,  embracing  cases 
of  the  most  hopeful  and  the  most  hopeless 


"ons.a„,::Vra„7;TS:trnf^"'''' 
ana;mia  prove  obstinate  to  alUr  °  ''""«'°°^ 

The  relation  of  arsen  c     ','™""™'- 
this  KrouD  of  nri„     """■'  '"s  a  remedy,  to 

ourcLests"  dTI?/""""'  ''  ^'""'^^  "f 
years  remarkabie'  re^  L"  11""'^'^  "  "  ''^'= 
from   its  use     fhi  "  '"^en  reported 

eluded  from  ou"c„r?  "'■''>'  "■"=   ""^  ex- 

""'ybein^rtl^ttire^'T"' 
practitioner  would  re„,,i  "'"  'h=>  a 

The  specific!"  on  STn  '°  T"^'"^'  "-'"-■ 
defective  haemoglobin  i™?h'  ""'"""«  ""= 
d-btless,  also,  I  st  m„ L  I'tZ";*"  """ 
of  new  ones,  is  one  of  ,T1  f"™wtion 

'herapentics  'in  which  detetl's  '""7"'  '" 
under  the  inflnence  of  ,1  ""''"'e-changes, 

wHhscie„tific"rc:ractrdrv':i""'"^ 
from  week  to  week.  ^       ''^^>'  ^'^"^ 

In  leukccmta  and  IIoJ?kh,\  .//<• 
has  been  extensively  t  Id   n  ''  ''■''"'■^" 

temporary  success   'wrt-sT""""^  "''^'^ 
"1  these  affections  th-it  fh  ""^  '"  "^'"^^ 

-^s  of  i,np.o::^S  Xra""""'  '•^- 
medication.  I  have  „,.,?,  "^  '^I"''"'al 
mia.  and  i.  must  be  ake.  S  "  '"  ""^- 
estimation  of  the  effect  „  "'"""  '"  °'"- 

ally,  T  have  not  seen         k    ''"""'>'•   '"e'^on. 

^f--nirinhrdSe"f'™ ''""»' 

--'ofthee,eve„=s:es;;i:er/r;n" 


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Montreal,  all  of  which  were  fatal.  In  Hody- 
kin's  disease  the  report  is  more  favorable.  In 
1883  I  had  two  cast's,  both  in  women,  in  which 
the  large  glands  of  the  neck  and  armpits  re- 
duced nialciially  under  the  prolonged  use  of 
Fowler's  solution,  but  I  do  not  know  the  sub- 
sequent history  of  the  cases.  Several  writers 
have  reported  most  satisfactory  results.  Ka- 
rewski*  had  three  recoveries,  and  of  eleven 
cases  treated  at  the  Stockholm  Hospital  five 
were  benefited. f  The  persisten'.  use  of  it  in 
full  doses  for  many  months  is  probably  the 
most  efificacious  remedy  we  possess  in  this 
disease. 

In  cases  of  splctiic  anccmia  of  non-malarial 
orig'n,  I  cannot  say  that  I  have  seen  any  spe- 
cial benefit  from  arsenic. 

\Ve  come  now  to  pernicious  anccmia,  in 
which  so  much  has  been  gained  by  the  judi- 
cious use  of  this  drug.  Pernicious  an;emia 
includes  cases  of  very  diverse  etiology.  Any 
severe  anemia  t'liding  to  a  fatal  termma- 
tion  may  well  be  termed  progressive  and  per- 
nicious. In  a  considerable  proportion  preg- 
nant y  and  parturition  appear  to  have  been 
detumining  factors,  while  others  can  be  di- 
rectly traced  to  defective  food,  as  in  many  of 
the  Zurich  and  Bern  observations.  E.xcluding 
these,  've  have  a  jiioup  of  cases  of  which  the 
etiolog)'  is  obscure,  and  to  which,  in  our  pres- 
ent knowledge,  the  terni.s  idiopathic  of  Addi- 
sion  hi.  J  essential  of  Lebert  are  applicable. 
'  'ery  year,  however,  we  are  reducing  the 
lib      of  cases  whic     wc  can  strictly  call 


*  Beyliiicr-  Klin.   Wochensc-    'ft,  1884,  17  ,niul  18. 
f  Abstiact  in  Year  Book  of  Tre.itincnt  for  1884. 


f^ 


J'opath.c.  It  is  reasonable  to  suppose  that 
he  extensive  ci,anges  in  the  bonrmar  >w 
onncl  ,n  certain  instances  are  directlyTeTa    d 

o  the  profound  cIisturlKu,ce  in  bloorforma 
t'on,  just  as  is  the  case  in  hynernl-isi-.  of  T 
spleen  or  of  the  lymph-lnd  An 
medullaris  ,s  now  very  generally  recognized 
I  nen,  there  are  the  nsps  ,^(  ,.  ■  '''"'^'^*^- 
mia  in  wh.Vh  fL  Pernicious  anre- 

m.a  in  which  the  primary  disturbance  seems  to 
be  m  the  gastro-i     .stinai  canal,  and  the  con 
i't.on  of  the  blood  the  direct  consequence "; 
he  impaired  nutrition.     There  remain  cases 
>n  which  none  of  these  conditions  prevail  and 
neither  during  life  nor  after  deathVo  w  "fi,  d 

such  f"'  1  ''•'  °''''^'"  "^  '"^^  —  a.  To 
uch,  or  he  time,  the  designation  idiopathic 
's  apphcable.  Clinically,  it  may  be  impo  i? 
be  to  distinguish  between  these  various  form 
and  the  etiology  is  often  very  obscure  and 
g.ves  us  no  help.  The  cases  w'hich  come  on 
dunng  or  after  pregnancy,  or  whic^  esult 

o  U,r,  as  a  rule,  a  more  hopeful  prcgnosis  • 

o    Zi  '"''"'  '"  ^^'^'^  'here  is  atrophy 

of  the  mucous  membrane  of  the  stomach  or 
ex  ensive   medullary  changes,  from  those    n 
which  these  conditions  are  absent.     A  m. 
carefnl  study  may  m  the  future  enable  us  to 

Terences  in  etiology  and   pathologv  because 

n    hem  will  possibly  be  found  th'e  ex^l      ! 

t-on^of  the  success  or  failure  of  certain  rem- 

.I'l""^  ?.'^^7  ^'^^"'^  ^^s  not  systematically 
employed  m  pernicious  anemia,  and  to  I  ^am 

well  IS  undoubtedly  due  the  credit  of  us  inZ" 


f.j 


■;    ■ ! 


ft 


10 

duction.     Neither  Muller*  nor  Eichorst.f  in 
their  elaborate  monographs  pubMshed  in  1877 
and  1878,  speai<  of  its  use.    i'adley.^  in  an  in- 
teresting review  of  the  question,  has  carefully 
analyzed  the  cases  in  which  arfienic  was  nut 
emplwyed,  and  finds  that  of  forty-eight,  forty- 
two    were    fatal,    while    of  twenty-two  cases 
treated   with  arsenic  sixteen   recovered,  two 
improved,  and  four  proved  fatal  ;  and  he  re- 
marks, that  "  in  the  whole  list  there  is  not. 
with  one  exception,  a  single  authentic  case  of 
recovery  in  which  arsenic  did  not  form  the 
chief  part  of  the  treatment."     Certainly  the 
reports  of  this  affection  since  iSSo  have  been 
much  more  encouraging,  and  it  need  not  ne- 
cessarily be  regarded  as  "almost  invariably 
fatal,"  to   u.se  the  words  of  a   leading  text- 
book.    Of  three  cases  of  pernicious  anaemia 
which  I  have  seen  this  year  two  have  already 
proved  fatal,  and  one  is  in  a  fair  way  to  re- 
covery. 

Case  I.— A  man,  aged  42,  I  saw  with  Dr. 
Henry.  We  reported  it  in  full  in  the  April 
number  of  the  American  Journal  of  Medical 
Sciences,  and  it  is  remarkable  as  an  instance 
of  pernicious  anaemia,  with  advanced  atrophy 
of  the  mucous  membrane  of  the  stomach. 
Arsenic  was  given  during  the  course  of  the 
disease,  but  not  for  any  length  of  time,  as  it 
seemed  to  bring  on  diarrhcta. 

Case  II.— A  woman,  aged  about  45,  I 
saw  with  Dr.  Weir  Mitchell  on  January  20. 
She  had  been  the  subject  of  dyspeptic  attacks 


*  De  Progressive  Perniciosc  Annemie.  Zurich,  1877. 
t  De  Progressive  Peniiciose  .\ncemie.  Leipzig,  1878. 
X  Lancet,  1S83,  ii. 


1 1 


for  some  years,  aiul  had  become  very  pale, 
and  during  last  year  the  ana;mia  reached  an 
extreme  degree.     With  rest,  systematic  feed- 
ing,  iron,  and  arsenic  she  improved,  and  was 
able  to  go  home  and    ittend  to  her  household 
duties.     I   saw  her  in    January  on   her  way 
South.     She   returned   in    March  very  much 
worse;    was   again    placed    on    the    plan   of 
treatment  which  had  proved  so  successful  in 
the  first  attack,  but  the  stomach  was  so  irrita- 
ble and  the  digestive  power  so  enfeebled  that, 
she  sank,  and  died  on  the  i8th  of  April.    The  ' 
improvement  in  her  first  attack  was  attrib- 
uted  by  Dr.  Mitchell  to  the  careful  feeding 
and  rest  as  much  as  to  the  medicine. 

(  ASE  III -An  active  business  man,  aged 
43  ;  Wien  M  arch  4.     H  istory  of  dyspepsia,  and 
for  the  past  si.K  months  failure  in  strength. 
Shortness  of  breath  on  the  slightest  exertion," 
and  at  times  attacks  of  agonizing  pain  at  the 
heart  resembling  angina.     He  had   not  lost 
much  tlesh  ;  indeed,  as  is  usual  in  these  cases, 
the    subcutanef)us   fat  was   well    developed! 
When  first  seen,   the  anaemia  was   marked  ; 
lips   and    tongue    very   pale,   and    sclerotics 
pearly.     The  general  surface  did  not  look  so 
pale,  on  account  of  his  dark  color  and  a  de- 
cided saffron-yellow,  sub-icteroid  tint  of  the 
skin.     The  temperature  was  a  little  elevated  ; 
pulse    100,  and  of  moderate  volume.     With 
the  exception  of  heart- murmur,  there  were 
no  symptoms  elicited  in  the  examination  of 
thoracic  and  abdominal  viscera.     The  blood 
showed  in  a  n;arke<i  manner  the  corpuscular 
changes  of^  advanced   anaemia.     The   blood 
count  could  not  be  made    at  the  time,  but 
when  I  next  saw  him,  two  weeks  later,  there 


I'-H 


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12 

were    only   700,000   red    corpuscles  to    the 
cubic    millimetre,    and    the    color    percent- 
age was  only  about  twenty.     He  was  put  to 
bed,  absolute  rest,  given  a  milk  diet,  ordered 
massage  once  a  day,  and  as  medicines  bis- 
muth and  carbonate  of  sodium,  with  Fowler's 
solution    n^v,  three   times  a  day,  to  be    in- 
creased one  minim  daily  at  the  end  of  a  week. 
He   had   been  taking,  by  the  advice  of  his 
physician,  an  elixir  of  iron  and  strychnine, 
which  was  continued.     For  two  months  there 
was  not  much  apparent  change,  though  the 
ratio  of  the  colored  corpuscles  increased  to 
over    1,500,000    per   cubic    millimetre.     The 
arsenic  had  been  pushed  to   15  drops  three 
times  a  day,  when  puffiness  of  the  eyelids  and 
forehead  came  on,  and  it  was  omitted  for  a 
week,  and  started  again  with  nj^v.    On  reach- 
ing "Ixiii  a  slight  red  rash  appeared,  and  it 
was  stopped,    and,    after   beginning    at    nj^v 
again,    he    reached    n^xx   t.  i.  d.     On    these 
large  doses  he  seemed  to  improve  more  rap- 
idly, Hnd  he  bore  them  for  two  weeks  or  more, 
when  gastric  irritation  supervened,  with  diar- 
rhoea.    The  drug  was  then  stopped  for  ten 
days,  and  pills  of  ^^  of  a  grain  of  arsenious 
acid  ordered.    On  January  31  he  was  allowed 
to  get  up.     By  June  13  he  was  able  to  move 
to  Cape  May.     The  bioo,d  condition  has  rap- 
idly  improved,    and    at   the    last   count    the 
corpuscles  were  nearly  4,000,000  to  the  cubic 
millimetre.     When  seen  on   September  7  he 
looked  remarkably  vigorous,  had  a  good  ap- 
petite, was  at  business,  and  feeling  very  well. 
It  would  be  incorrect  to  attribute  the  success 
in  this  case  entirely  to  the  arsenic,  but  rather 
u>  the  plan  of  treatment,  in  which  it  was  a 


III 


les  to  the 
If  percent- 
was  put  to 
et,  ordered 
licines  bis- 
th  Fowler's 

to  be  in- 
I  of  a  week, 
nee  of  his 
strychnine, 
:)nths  there 
;hough  the 
creased  to 
etre.  The 
rops  three 
syelids  anfj 
itted  for  a 

Or.  reach- 
red,  and  it 
ig    at    njjv 

On  these 
more  rap- 
:s  or  more, 

with  diar- 
;d  for  ten 

arsenious 
as  allowed 
;  to  move 
n  has  rap- 
:ount    the 

the  cubic 
iber  7  he 

good  ap- 
very  well. 
le  success 
3ut  rather 

it  was  a 


13 

very  important  factor.  It  will  be  found,  I 
think,  that  absolute  rest  in  bed,  with  daily 
massage,  and  the  strictest  attention  to  feed- 
ing, are  most  important  features  in  the  suc- 
cessful management  of  these  cases. 

Arsenic  has  been  spoken  of  as  ::  specific  in 
psrnicious  annemia.     This  is  a  mistake.     The 
disease,  as  I  have  indicated,  is  so  varied,  and 
results  from  the  operation   of  such   diverse 
causes,  that  we  cannot  expect  any  one  remedy 
to  be  uniformly  active.     In  a  majority  of  the 
cases  iron   is  useless,  but  it  sometimes  suc- 
ceeds  after    arsenic    has    failed    absolutely. 
Such  a  case   was   reported    by   Finlay*   last 
year,  which  was  cured   by  iron  after  a  thor- 
ough and   but  ineffectual  use  of  arsenic.     I 
do  not  think  we  understand  fully  the  condi- 
tions in  which  it  is  most  serviceable,  and  for 
the  time  we  must  be  content  to  employ  it  em- 
pirically, on  faith  of  the  success  which  has  at- 
tended its  administration  in  so  many  cases. 
Ultimately,  we  may  hope  to  be  able  to  dis- 
criminate between   the  cases  which  call   for 
iron  and  those  in  which  arsenic  is  indicated, 
and  with  this  object  in  view  the  cases  which 
come  under  observation  should  bt  carefullv 
studied. 

Mode  of  Admimstration. — I  usually  give  the 
liquor  arsenicalis  (liquor  potassii  ansenitis), 
beginning,  in  an  adult,  with  n^v  three  times  a 
day.  Occasionally  this  is  found  too  much, 
and  I  reduce  the  amount  to  2  or  3  minims. 
After  ten  days,  if  well  borne,  I  order  an  in- 
crease of  a  minim  each  day,  so  that  by  the 
end  of  the  second  week  the  patient  is  taking 

*  Lancet,  1885,  •• 


.    C 


:  • 

J 

I 

> 

" 

J 

r 
) 

:!■■ 


ill! 


m\ 

'aWMIi 


lo  or  12  minims  three  times  a  day.     This  is 
kept  up  for  a  week,  and  then  gradually  in- 
creased until  the  physiological  effects  are  ob- 
tained.    The  amount  which  will  induce  these 
varies  with   different  individuals,  and  those 
who  bear  it  best  seem  to  improve  the  most 
rapidly.     I  have  thought  sometimes  that  the 
small  doses  are  not  so  well  borne  as  larger 
ones,  and  are  more  likely  to  cause  gastric  ir- 
ritation.    Young   people  bear  it  remarkably 
well.     Within  the  physiological  effects  there 
is  no  special  limit  to  the  quantity,  and,  as  in 
chorea,  I  make  them  my  guide  in  the  admin- 
istration.    A  very  important  point  is  the  con- 
tinuous use  for  many  weeks  or  months,  omit- 
ting for  a  few  days  if  unpleasant  effects  arise. 
Even  after  apparent  recovery  I  advise   the 
continuance  of  the  drug.     When  the  liquor 
arsenicalis  is  not   well   borne,  the  arsenious 
acid  in  pills  maybe  tried,  or  the  solution  may 
be  given  hypodermically.     In  these  cases  of 
severe   anaemia   I    never  care  to    use   hypo- 
dermic   injections    systematically,  as  I   have 
seen  ecchymosis  of  the  tissues  follow,  and  in 
several  instances  distressing  small  abscesses. 
By  the  rectum,  it  is  usually  well  borne. 


.  This  is 
idually  in- 
;ts  are  ob- 
luce  these 
and  those 

the  most 
5  that  the 

as  larger 
jastric  ir- 
;markably 
;cts  there 
ind,  as  in 
ie  admin- 
3  the  con- 
ths,  omit- 
jcts  arise, 
ivise  the 
he  liquor 
arsenious 
ition  may 
:  cases  of 
se  hypo- 
s  I  have 
IV,  and  in 
ibscesses. 
le. 


(' 


I. 


,7 


DUODENAL  ULCER. 


The  solitary  ulcer  occur?  more  frequently  in  ^h.  a     ^ 
than  in  any  other  portion  of  th.      7"^"*^^  '"  ^^^  duodenum 

and  -rbid'natomfi      ,11  tLntl  :'">;'",'  '"  '''  '^^'^'^=^ 
It  is  rarely  met  with  bei:!  ^  t  'n^  a  '^n^^'^-  "'"''• 

acid  chyme  is  neutralized.    Bloo<l  stasis  in  I  .        "      T"'  '^' 
of  the  mucous  raembrinp  i^  .r         ^  circumscribed  area 

Jh.ch  actual  disease  of  a  vessel  has  bee„  2JZZ  Tv      '" 
fi™  m  a  striking  manner  this  view,     Th„   Me  fei  ft  ^     " 

r::,i  i::t:t:r  rr  ^-  -f'-  - 1: 

su"<rest<?  flnf  ;«  ti     J     1  ^  vit.vv.    ine  Jollowm;f  case 

Wscs  that  m  the  duodenum  there  is  nossiblv  ar,.fu  , 

m  which  ulcers  may  arise  :-  ^         ^  ^"^*^''  "'°'^« 


(■    i' 


s     ,; 

"     'v  *      lisl 

>* 

^ 

f 

) 

i   ' 

M  li 

, 

i  V 

f> 

'!/* 


•'•iMa 


:     »; 


'ill 


!  Ill, 


i  f 


Case  I. — Phthisis  ;  small  ulcers  in  ileum  ;  ulcers  in  ccecum 
and  colon  ;  an  ulcer  in  duodenum  half  an  inch  outside 
pyloric  ring  ;  cyst  of  Brunner's  gland. 
J.  L,  rniddle-aged  man,  died  of  phthisis  in  Montreal  General 
Hospital.     No  special  symptoms.     The  lungs  showed  cavities ; 
the  heart  valves  were  normal.     There  were  a  few  small  ulcers 
in  the  lower  patches  of  Peyer,  and  a  number  of  small  ulcers  in 
cajcum  and  colon.     Just  outside  the  pyloric  ring  there  was  a 
loss  of  substance  in  the  posterior  wall  of  the  duodenum  1.5  cm. 
in  diameter.     The  base  was  smooth,  the  edges  overlapped  so 
that  the  actual  diameter  of  the  ulcer  was  much  greater  than  was 
apparent.     Not  far  from  this  there  was  a  small  dark  spot,  with  a 
little  depression  leading  into  a  definite  cyst-like  cavity  in  the 
submucosa  the  size  of  a  large  pea,  which  contained  a  thick  turbid 
fluid.  Brunner's  glands  were  very  distinct,  but  not  more  so  than 
is  often  seen  when  the  mucosa  is  thin,  and  not  deeply  congested. 
The  open  ulcer  with  undermined  edges  had  possibly  resulted 
from  the  rupture  of  a  cyst  of  a  Brunner's  gland  similar  to  tlie 
one  which  existed  in  its  vicinity.     One  can  readily  understand  ' 
that  under  such  circumstances  the  thin  mucosa  covering  the  cyst, 
undermined  and  separated  from  its  blood  supply,  might  be  eroded^ 
or,  after  bursting,  the  acid  gastric  juice  might  dissolve  the  thin 
edges.     In  debilitated  persons,  or  in  conditions  of  portal  con- 
gestion, such  a  small  erosion  might  not  readily  heal,  but  rather 
increase,  and  be  the  starting  point  of  an  ulcer.   Brunner's  glands 
are  not  often  found  diseased,  but  they  belong  to  the  racemose 
variety  in  which  cystic  dilatation  of  acini  is  not  uncommon.  They 
exist  most  abundantly  on  the  first  portion  of  the  duodenum,  the 
region  most  prone  to  the  disease. 

Duodenal  ulcer  is  not  so  frequent  as  the  ventricular.  I  am 
sure,  from  my  own  experience,  that  it  would  be  oftener  found 
if  the  stomach  and  duodenum  were  opened  toge'ther,  in  situ,  and 
the  mucous  membrane  examined.  If,  as  is  so  commoidy  done, 
the  stomach  is  cut  away  just  beyond  the  pyloric  ring,  the  chances 
are  that,  if  an  ulcer  is  present,  the  incision  passes  through  it. 
I  have  found  nine  cases  In  about  one  thousand  dissections. 
Males  are  more  subject  to  ulcer  of  the  duodenum  than  females. 


l-fl 


a.e^     0„e  of™,  ease,  „,  in  li^t^r ""'  '"  ™^^'» 

of  the  , as.™  „,ce.  ha,  ..'o  spilrhle^f"  ^^  P""-"™ 

-r=— -----;..W..3,a3 

Case  ll.—PhtJn^^^  .   „  . 

J-nrnms,    extensive    ulceraimr,    ^f  •; 

E-G.,  a2ed23  diod  in  n     at  ^^^yM  jaundice. 

'■-saa,  »;™p.™/Xh:t^:,r'  rr""  "°'^""  -■"• 

a"J  abJ,„m„a|   tcnilereess    h,„  „  ■  }"'"  "'""'  '"'"■"•I'^a 

showed  cavitie,  i„  bo  h  „„' ,    Ex'"  ■  '"'"f  ""■     '^''^  ""'"P'* 
of  ileun,,  e^cum  and  colon" ti.lf  f      T  "''"''"''•""  "'"""'io" 
»ion  f,.„,„  the  ba,es  of  .  ^      ^   ,"  ,r"'°"'''"'"=  ■"  ^--'- 
Pa.-tofduoden„n,  was  a  circl „  ,.  e"r   t  ThH'V""  °""' 
■immele,-,  with  dean  out  orl»es  an,i  ,,„    H   T  °"  '""''  '» 

-™t  origin.   U  did  no.  invtive     '        t:"'^],,  ''  '°»^«^  »f 
ges  .on  of  .he  mueons  „e„,b,.a„o  of  .he    „    et„„      I  ""  '™- 

"leer  the  size  of  a. en-cent  niece  t!h  '    "'  """■"  ™  an 

"»'  .»o  inches  f,.o„  .heto':::  ''7z:t^  ^tr'- 

'»ere  no  signs  of  ,„,,erc|e  in  the  base  „f  .1       ,  '=''  """■" 

l.«en  01  this  „..,are.     In  Kraus,'  ,U  ■         '  "  "'"^  '""" 

=-oes  of  olee.  ,„  connectrritrphrsL  ''"'  ""'  '^™  - 


// 


r 


!^^*  ■ 


6 

I  have  not  met  with  a  duodenal  ulcer  in  death  from  extensive 
burns. 

In  all  of  the  cases  the  ulcer  was  solitary,  and  occupied  the 
first  or  horizontal  part  of  the  gut.  The  form  was  round  in  all, 
and  the  diameter  ranged  from  half  an  inch  to  an  inch  and  a  half 
The  base  was  either  the  submucosa,  the  head  of  the  pancreas, 
or  thickened  connective  tissues.  In  Vases  III  and  IV  the  ulcer 
had  cicatrized.  The  edges  were  usually  rounded  and  not  under- 
mined. Perforation  into  the  peritoneum,  which  occurs  so  fre- 
quently, was  not  met  with.  Perforation  of  a  duodenal  artej-y 
occurred  twice  with  fatal  hemorrhaf'e. 

Two  of  the  cases  illustrate  healing  of  the  ulcer,  one  with  and 
the  other  without  alteration  in  the  lumen  of  the  tube. 

CASElll.—  Tt/phoid  fever;    illness    of  fourteen  days ;    per- 
foration; peritonitis;  cicatrix  of  ulcer  in  duodenum. 

A.  B.,  aged  40,  night-porter  at  Montreal  General  Hospital, 
had  been  ill  for  two  weeks  with  typhoid  fever,  when  perforation' 
took  place,  and  death  followed  in  eighteen  hours  from  acute 
peritonitis.  The  post-mortem  showed  extensive  ty[»hoid  lesions 
and  a  perforated  ulcer  one  foot  from  the  ileocecal  valve.  In 
the  first  portion  of  the  duodenum,  an  inch  from  the  pylorus,  on 
the  anterior  wall,  was  a  stellate  cicatrix  about  three-quarters  of 
an  inch  in  diameter.  There  was  slight  puckering  in  the  vicinity, 
but  no  narrowing  of  the  gut.  The  heart  and  valves  were  nor- 
mal.    A  few  patches  of  atheroma  on  the  aorta. 

This  illustrates  the  most  favorable  termination  of  an  ulcer. 
Such  cicatrices,  according  to  some  authors,  are  not  uncommon. 
They  have  been  so  in  my  experience. 

CAi^^lY.—PhtJusis;  healed  ulcer  of  duodenum,  with  stc-nvm 
of  first  portion  ;  dilatation  and  hypertrophy  of  stomach. 
S.  F.,  aged  35,  had  been  in  medical  wards  Philadelphia  Hos- 
pital for  six  months  with  symptoms  of  advanced  phthisis.  He 
had  on  several  occasions  coraplaiuod  of  gastric  pain,  and  at  times 
vomiting  was  a  troublesome  symptom  ;  but  attention  was  no 
specially  directed  to  the  abdomen. 


I// 


im  extensive 

)ccupied  the 
•ouiid  in  all, 
1  and  a  half, 
le  pancreas, 
Fthe  ulcer 
1  not  under- 
curs  so  f're- 
enal  aitoj-y 

le  with  and 


nys ;    per- 
uodenum, 

1  Hospital, 
perforation 
rora  acute 
loid  lesions 
valve.  Ill 
)ylorus.  on 
luiirters  of 
le  vicinity, 
wore  iior- 

an  ulcer, 
ncommon. 


f  stomach. 

Iphia  Hus- 
lisis.  He 
id  at  times 
1  was  no 


Po8t.7nortem.— Extensive  pulmonary  tuberculosis.     Stomach 
•  moderately  dilated  ;  mucous  membrane  thick  ;  muscular  walls 
at  least  twice  the  normal  diameter.     Pyloric  ring  of  normal  size 
a  httle  firmer  and  thicker  than  usual.     Duodenum,  for  three- 
fourths  of  an  inch  beyond  the  ring,  normal  and  had  a  circum- 
ference of  two  and  a  half  inches.     Beyond  this,  at  a  distance 
of  about  one  inch  from  the  ring,  there  was  a  stricture  admittin.r 
the  top  of  the  little  finger.     When  slit  open,  it  extended  one 
and  three-fourths  inches,  and  measured  one  inch  in  circumfer- 
ence.    The  narrow  portion  reached  nearly  to  the  bile  papilla. 
There  was  not  much  thickening  of  the  coats  at  this  part,  indeed 
m  places  it  was  very  thin,  and  the  texture  of  the  pancreas  could 
be  seen  through  the  thin  wall.     Towards  the  stomach  there  was 
puckering  and  greyish-white  cicatricial  tissue.     The  ulcer  ap- 
peared to  have  completely  healed  except  at  one  small  spot 
ihere  was  pigmentation  of  the  tissues  of  this  portion  of  the 
bowel ;  not  much  thickening  of  the  contiguous  parts  attached 
to  the  stenosed   portion.      There  had  evidently  been  an   ex- 
tensive ulcer,  which  had  healed  and  produced  stenosis  just  as 
happens  not  infrequently  in  gastric  ulcer  when  near  the  pylorus. 
Cases  are  reported  in  which  the  ulcer  has  perforated  the  liver 
or  eroded  the  portal  vein  or  the  hepatic  artery.     The  followin.r 
case,  in  which  1  performed  the  autopsy  for  Dr.  Rodger,  is  re*^ 
raarkable,  inasmuch  as  the  ulcer  perforated  the  gall-bladder, 
eroded  the  tissues  in  the  hilus,  and  ultimately  divided  the  right 
branch  of  the  hepatic   artery,  from  which   the   patient  bled  to 
death.    There  are  four  other  instances  in  literature  in  which 
tins  occurred,  and  in  the  first  published  case  of  duodenal  ulcer 
by  Broussais   (quoted  by  Chvostek)   the  hepatic  artery  was 
eroded : —  ^  j 

Case  Y. —Jaundice  for  more  than  three  months ;  repeated 
hoimorrhagesfrom  stomach  and  bowels  ;  large  ulcer  of 
duodenum;  perforcHou  of  gall-bladder ;  erosion  of 
right  branch  of  hepatic  ariry. 

Mrs.  R.  S.,  aged  48  years,  c.  stout,  well-nourished  person. 
I  ho  following  notes  have  been  furnished  by  Dr.  Rodger,  under 
whose  care  the  patient  was : 


if 


I' 

s 
* 


!i 


«# 


'^ 

[\i\- 


1 1 


'.: 


u 


8 

"  She  had  been  married  upwards  of  twenty-four  years,  but 
never  had  been  pregnant ;  menstruation  had  been  regular,'  but 
had  ceased  about  three  years  ago. 

"  The  only  ilhiess  of  consequence  that  she  ever  had  was  about 
fifteen  years  ago,  when  she  was  laid  up  in  bed  for  about  six  weeks 
with  what  was  called  an  attack  of  inflammation  of  the  liver.  No 
jaundice  was  perceptible   at  that  time.     Ever  since,  however, 
she  has  been  troubled  with  dyspepsia,  obstinate  constipation,  and 
more  or  leas  pain   n,-  feeling  of  discomfort  in  the  region  of  the 
stomach.     Her  condition  to-day  (March  18th,  1879)  is  that  of 
a  person  suflfering  from  a  well-marked  attack  of  jaundice ;  skin 
and  conjunctivae  deeply  tinged  ;  urine  dark,  and  stools  pipe-clay 
m  color ;  tongue  coated  ;  loss  of  appetite  ;  no  increase  of  tem- 
perature.    Slu-  states  that  she  has  not  felt  well  all  winter,  but 
was  always  able  to  attend  to  her  household  duties. 

"  Patient  came  to  my  office  for  about  four  weeks,  at  the  end 
of  which  time  the  symptoms  had  not  improved. 
_  "  On  April  24th,  visited  the  patient  at  her  house.  Examina- 
tion revealed  no  enlargement  of  the  liver,  and  only  slight  tender- 
ness on  firm  pressure  over  the  organ.  Heart  and  lungs  healthy, 
"  Has  noticed  considerable  blood  at  stool  during  the  past  few 
days,  and  fyeces  still  pipe-clay  in  color.  No  haemorrhoids.  Dr. 
G.  W.  Campbell  saw  the  case  in  consultation,  and  gave  a  very 
unfavorable  prognosis,  though  the  exact  nature  of  the  disease 
was  doubtful. 

"  All  treatment  adopted  proved  of  no  avail ;  the  patient 
rapidly  became  emaciated,  and  continued  deeply  jaundiced. 
Several  severe  attacks  of  epistaxis  have  occurred  lately,  and 
to-day  (May  30th)  has  passed  more  blood  than  usual  by  stool. 

"At  3  p.m..  May  Cist,  commenced  vomiting  blood,  and  con- 
tinued to  do  so  frequently  all  afternoon,  in  spite  of  treatment 
The  hemorrhage  from  stomach  and   bowels  became  excessive, 
and  death  followed  in  a  few  minutes." 

Autopsy.— Hody  that  of  a  well-nourished,  moderately  stout 
woman.  In  abdomen,  coils  of  intestines  dark-colored  from  stain- 
ing of  mucosa  ;  peritoneal  layer  smooth.  Liver  dark-colored  ; 
the  ascending  colon,  the  stomach  and  duodenum  are  closely  ad- 


/I 


9 

hercnt  to  the  under  surface  of  it«  nnf    • 
duodenum,  pancreas  S^LTZT'T  '°"'^''"-     ^^^'"^^h, 
dilated  and  contains  ^1X1^^'^  >"""^-     ^^^-^ 
mucosa  dark  and  blood-stained  oi  remnants  of  food  ; 

"ormal.  Immediately  outside  it's  wpIi  "'"7  ''''^-  ^^'"''"s 
and  back  part  of  the'duod  L^  TT^f  '"f  '"  '''  "P^^ 
length  and  1- :,  cm.  in  breadth  T.  •  ^  ""^"''  ^"^  ^'»-  '» 
clots,  on  the  removal  of  .hid  .n  kI'  ^'"""^  ^^''^''^  ^"'^ 
occupying  the  under  surfac  o  th  U  '  ""f'^  '^  ^'««'°«^d, 
gall-bladder.  The  ed^os  of  the  o  fi  '  '"  '"'"'""  ^^  ^^^ 
and  the  two  fingers  ca^n  it  L  H:;!  ^"^"""  ^"^  -""^^ 
second  joint.     A  good  deal  of  tit  ''"'^  ''  ^'^  "'  ^^« 

denum,  where  it  is^ttaeh:!!:; t^^^^^^^^^^^^^  ^^  ^he  duo- 
brane  is  not,  however,  puckered  ...  ,  "  '^^"^''"^  "^em- 
normal.  The  followi  Ji  .e  '  r  "'  ''"  ''"^  ^^'  ''^  ^^^^^^  is 
hepatico-duodenal  lig."met     Porta  '  ''  ""  ''""^^  '"  *»'« 

f  e.  Common  bile  dul  Lfol  """e  ""k"'"''  ""'•-^'  '" 
the  upper  margin  of  the  ulce  vhere  i"  '""'  '^"'^  ^« 
least  the  probe-pointed  scissors  cu  down  /T""'  '°  '^P^" '  ^^ 
orifice  at  this  situation,  and  it  cou  ,  l"  ^^  f^^  ^'^P^-'  ^l- 
has  probably  been  cut  across  by  the  ulc  r  VV  n  '"^^^-  ^' 
B'anches  in  the  liver  norm.l  ^"'  ^^'"^"^  are  thickened, 

s-all  orifice,  into  whici     l^e   ,ro         '''''  ^'^'  >'"^  ^'  ^y  a 

;^- -ts  with  an  o^itrir :  z  ri^y^  ^"•'  '"^ 

hepafc  artery,  when  slit  up,  is  n.turnll  '  '"'-     '^'''« 

the  hranches,aprobeinserted  into  M  '1'"°'  '"  ^""^^''^S 

branch,  which  passes  back,  ardl  "  """  ''"^""  ''  ^'^  ^'ght 
-d  of  the  g-all'bladclrra  r  ';:;  :r;r''^^-f  -  the  upp^r 
to  be  ulcerated  through  in  a  sp  %'!  T  ''T"  '«  -- 
communicates  freely  with  the  L  Th  ^.'"u,'  '^^  '"««'^' 
exposed,  and  is  found  in  a  c  ndi'L  r  t  ^^''-^'^dder  was  then 
the  upper  part  is  there  any  a  "of  l"'""^'^"'  ^"'^  ^^-^ds 
rest  of  its  extent  the  wall  i     'n         ,  '"^'"'^'''^"^  '  '"  the 

Ploughing.     There  is  a  deen       f '  "''^'  '"^'  >"  P'^'^es, 

the  liver' the  tissue  f  whcTat';^:"''':""  ^""^'^  '''  ^^'-  «^' 
-^'-  It  is  here  .hereto  ujjr;^,^'"^'  ^"'  ^'^"^''^• 
place.     The  ««.endin..  colrn     !  ''  ^''^''^  ^'««  taken 

-endm^  colon,  close  to  the  flexure,  is  adherent  to 


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the  gull-bladder,  and  between  the  two  there  exists  a  circular 
orifice  -f  coinmunication,  7  m.  in  diameter,  with  rounded  edges. 
Death  not  uncommonly,  takes  place  by  gradual  exhaustion, 
consequent  upon  repeated  vomiting. 

Case  Yl.—Symptoms  of  gastric  ulcer  for  many  months; 
progressive  emae-iation  ;  large  irregular  ulcer  just  out- 
side pyloric  ring. 

W.  VV.,  aged  72,  patient  of  Dr.  Wilkins.  Well-marked  symp- 
toms of  ulcer,  supposed  to  be  gastric.  Death  took  place  slowly, 
after  many  months  illness. 

Autopsy.— Hody  much  emaciated.     In  abdomen,  peritoneum 
dull  and  lustreless  ;  two  pints  of  turbid  fluid,  mixed  with  lymph, 
removed.     Stomach  appears  dilated.     (Esophagus  presents  in 
its  terminal  part  an  oval  area,  3-5  by  1-2  cm.,  from  which  the 
mucous  membrane  has  been  completely  removed  by  the  action 
of  tie  gastric  juice.     In  the  centre  a  thin  external  layer  alone 
remains.     Stomach   moderately  dilated,  and  contains  a  dirty- 
looking,  highly  acid  fluid.    Mucous  membrane  pale  ;  that  of  the 
fundus  thin,  owing  to  p3st-mortem  solution.     At  the  pyloric  end 
It  is  thick,  and  present  numerous  mammillatiohs.     The  pylorus 
is  greatly  narrowed,  admitting  only  the  top  of  the  little  finger 
as  far  as  the  root  of  the  nail.    On  slitting  open  the  ring  and  the 
duodenum,   the  following  condition  is  objerved :  PyTorus  not 
thickened  ;  ring  prominent,  but  not  more  so  than  is  often  seen. 
Immediately  external  to  it  is  an  irregular  ulcer  extending  round 
the  greater  part  of  the  circumference  of  the  gut,  and  presenting 
an  imperfect  division  into  two  portions,  the  larger  of  which  occu^ 
pies  the  lower  part  of  the  tube,  resting  upon  the  pancreas,  the 
other  being  placed  above  and  to  the  right.   The  extreme  length 
of  the  ulcer  is  3-7  cm.,  the  breaath  ranges  from  (5  to  13°ra. 
The  edges  are  round  and  somewha:  undermined.     The  base  is 
formed  of  firm  fibrous  tissue  of  a  greyish-white  color.     Close  to 
the  lower  edge  there  is  seen,  on  the  floor,  a  small  nodular  body, 
looking  like  the  end  of  a  closed  artery.    The  mucous  membrane 
of  the  duodenum  near  the  ulcer  is  greatly  puckered,  particularly 
the  upper  part.    The  bile  papilla  is  about  5  cm.  below  the  ulcer. 


-fi 


11 

Nothing  of  special  note  in  the  other  organs  beyond  the  atrophy 
of  extreme  emaciation. 

The  symptoms  of  duodenal  ulcer  are  extremely  variable  and 
rarely  distinctive  enough  to  make  the  diagnosis  more  than 
probable.  In  very  many  cases  the  process  is  latent,  and  the 
first  symptom  may  be  hemorrhage  or  peritonitis  from  perforation. 
In  others  the  ulcer  is  accidentally  found  post-morieaji,  and  has 
had  no  apparent  influence  in  the  course  of  the  disease  from  which 
the  individual  has  died,  as  in  the  following  instance  : — 

Case  VII.  —  Spinal    curvature;  bronchitis,   pulmonary  col- 
lapse; ulcer  in  first  portion  of  duodenum  ;  no  symptoms. 

M.  G.,  a  boy  aged  12,  admitted  to  the  Montreal  General 
Hospital  in  March,  1877,  with  bronchitis.  He  had  great  defor- 
mity of  the  iipino,  with  contraction  (vertical)  of  the  thorax.  He 
becime  very  cyanotic,  and  died  in  about  a  week.  There  was 
intense  bronchitis,  with  splenization  of  lower  lobes  of  the  lungs. 
The  right  ventricle  was  large  and  the  walls  thick.  The  valves 
on  both  sides  were  normal.  The  mucous  membrane  of  stomach 
and  intestines  was  co.ngested  ;  in  the  jejunum  the  edges  of  the 
valvulse  conniventes  were  in  places  ecchymosed.  In  the  first 
part  of  duodenum,  one  aiid  a  half  inches  from  the  i)ylorus,  there 
was  a  punched  out  ulcer  in  the  posterior  wall,  about  1-5  centi- 
metres in  diameter.  The  edges  were  well  defined,  the  base 
made  up  of  the  muscular  layer,  and  there  was  no  special  thick- 
ening in  tlie  neighborhood. 

In  essential  details  the  symptoms  of  the  duodenal  are  identical 
with  those  of  the  gastric  ulcer.  There  are,  however,  certain 
peculiarities.  Dyspepsia  is  not  so  constant  a  feature  in  duodenal 
ulcer,  and  may  not  amount  to  more  than  a  slight  feeling  of  un- 
easiness some  time  after  eating.  In  Chvostek's  list  of  cases 
collected  since  1865,  there  were  44  in  which  this  symptom  was 
specially  referred  to,  and  of  the  entire  number  only  liJ  had  loss 
of  appetite  and  uneasiness  after  eating. 

Vomiting  is  a  variable  symptom,  and  was  only  present  in  one- 
fourth  of  Chvostek's  list  of  cases.  Usually  it  occurs  at  the  end 
of  attacks  of  severe  pain. 


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Hemorrhaire  is  a  common  symptom,  occurring  in  a  third  of 
the  cases,  and  the  blood  may  be  either  vomited  or  passed  in  the 
stools,  01  appear  in  both. 

Case  YllL~aastric  symptoms  for  seven    or  eight   years; 
attacks  of  sever,  gastralyia  ;  prolonged  periods  of  free- 
dom :  hemorrhage  from  stomach  and  bowels. 
M.  I.,  aged  40,  patient  of  Dr.  F.  W.  Campbell.     This  case 
was  remarkable  for  the  long  duration  of  the  symptoms,  the  severe 
gastralgic  attacks,  and  the  remarkable  periods  of  freedom  from 
troublesome  symptoms.  He  had  on  several  occasions  hemorrhage 
from  the  bowels  without  haematemesis,  and  this  feature  of  the 
case  led  Dr.  F.  W.  Campbell  and  Dr.  R.  P.  Howard  to  suspect 
that  the  condition  was  one  of  duodenal,  not  gastric,  ulcer. 

Autopsy  —Moderate  emaciation.  In  abdomen,  stomach  ap- 
pears a  httle  dilated  ;  lower  coils  of  small  intestine  dark-colored 
Nothmg  special  in  thorax.  Stomach  somewhat  dilated;  walls 
ot  moderate  thickness.  Mucous  membrane  pale  ;  at  the  cardiac 
end,  thin.  Pyloric  ori^  is  narrowed,  admitting  the  little  finger 
to  the  second  joint.   ^  .lit  open,  there  is  no  special  thicken- 

ing ;  but  the  mucosa  is  puckered,  and  presents  an  elevated  rid-^e 
Duodenum :  Part  immediately  outside  the  ring  much  narrower 
than  adjacent  regions,  measuring  only  3-7  cm.      About  10  m 
from  the  pylorus  there  is  an  oval  ulcer  2-5  by  1  8  cm ,  e.xtend- 
lug  in  direction  of  axis  of  gut,  and  occupying  chiefly  the  posterior 
section  A  Che  tube.     It  is  deep,  with  rounded  edges,  which 
toward  the  upper  and  back  part,  are  undermined  for  about  6  m 
In  places  the  floor  of  the  ulcev  is  quite  (J  or  7  m.  below  the  level 
of  the  mucosa,  and  presents  a  tolerably  smoth,  fibrous  appear- 
ance.    The  head  of  the  pancreas  forms  the  base  of  the  lower 
three-tourths,  the  upper  part  is  protected  only  by  the  thin  mus- 
cular walls  of  the  first  piece  of  the  duodenum,  the  peritoneal 
surface  of  which,  at  the  site  of  the  ulcer,  is  puckered  and  cica- 
tricial.    Immediately  in  the  centre  of  the  floor  is  a  small,  dark, 
blood-stained  elevation,  consisting  chiefly  of  fibrin.  On  iniectin.' 
water  through  the  hepatic  artery,  small  clots  are  washed  out  at 
this  point,  and  the  water  flows  freely  into  the  ulcer  through  an 


13 


opening  in  the  gastro-epiploica  dextra,  2  m.  across,  and  with 
smooth  edges.  The  papilla  of  the  bile  duct  is  6  cm.  below  the 
ulcer.     Nothing  else  of  note  in  intestines. 

Case  IX.—Severe  gastralgio  attacks  for  six  months ;  slight 
dgspeptic  symptoms ;  hemorrhage  from  stomach  and 
boweh. 

J.  G.,  aged  45,  seen  with  Dr.  Whiteside  June  13th,  1885. 
Patient  was  a  large,  stout  man,  who  had  been  strong  and  healthy. 
He  had  taken  alcohol  freely,  and  of  late  has  had  business  worries. 
No  history  of  syphilis,  lie  had  suffered  at  times  with  dysf^epsia, 
but,  as  a  rule,  he  had  a  good  appetite  and  good  digestion.  In 
February  he  began  to  have  pains  in  the  abdomen.  The  first 
attack  came  on  suddenly  one  night,  and  was  so  severe  that  he 
got  no  sleep.  They  have  recurred  on  and  off  ever  since,  most 
frequently  at  night,  lasting  from  one  to  three  hours.  He  described 
th .'  pain  as  starting  in  the  epigastric  region  and  passing  to  the 
back  and  round  the  sides.  He  Avould  frequently  sit  on  the  edge 
of  the  bed  for  hours  doubled  with  the  pain.  In  the  intervals  of 
the  paroxysms  there  was  a  dull,  heavy  sensation  in  epigastrium. 
There  was  never  any  vomiting  with  these  attacks.  Food,  he 
insisted,  had  no  special  influence  one  way  or  the  other  in  induc- 
ing or  aggravating  the  pain.  Sometimes  there  was  a  sense  of 
oppreosion  after  a  full  meal.  Pressure  often  gave  relief  during 
the  paroxysm.  Since  February  he  has  not  been  a  week  free 
from  attacks,  and  has  lost  between  30  and  40  lbs.  in  weight. 

Inspection  showed  a  stout,  well- nourished  man.  Face  pale, 
tongue  lightly  furred  ;  pulse  104,  tension  increased.  The  ab- 
domen large  and  fat,  and  in  the  epigastric  region  there  wa  ,  a 
remarkable  throbbing,  most  distinct  about  two  inches  and  a  half 
from  the  ensiform  cartilage,  but  a  large  wave  of  pulsation  passed 
over  the  whole  abdomen  from  this  point.  The  shock,  indeed,  of 
the  pulsation  was  unusually  forcible,  and  was  perceptibly  com- 
municated to  the  bed.  The  heart  impulse  was  not  very  marked. 
On  palpation,  there  was  a  sense  of  deep  resistance  between  navel 
and  ensiform  cartilage,  but  no  distinct  tumor  could  be  felt,  no 
thrill.     The  thick  panniculus,  howeverj  made  the  examination 


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14 

very  difficult.  The  throbbing  was  very  violent  with  each  systole, 
but  the  pulsation  which  could  be  felt  was  trifling  in  comparison 
with  the  visible  pulsation.  This  1  underlined  in  ray  notes.  The 
spDt  where  it  was  most  distinct  corresponded  to  a  point  a  little 
more  than  two  inches  from  the  ensiform  cartilage.  There  was 
no  expansile  movement ;  no  dullness.  There  was  no  dilatation 
of  stomach.  On  auscultation,  a  systolic  murmur  was  heard  at 
ensiform  cartilage  and  for  one  and  a  half  inches  below  it,  also 
audible  in  7th  and  8th  left  costal  cartilages.  In  these  positions 
it  was  a  distant  but  very  distinct  murmur.  In  the  genu-pectoral 
position  the  throbbing  was  less  marked,  but  no  tumor  could  be 
felt.  IJo  murmur  could  be  heard  at  the  back,  and  there  was  not 
special  tenderness  over  spines.  The  liver  and  spleen  were  nor- 
mal. There  was  a  soft  systolic  murmur  at  apex  of  heart,  and 
the  second  aortic  sound  was  very  sharp  and  clear. 

I  only  saw  the  patient  on  this  occasion  and  a  positive  diagnosis 
was  not  reached.  Three  possibilities  were  discussed — ulcer  of 
stomach,  aneurism  of  abdominal  aorta,  and  deep-seated  tumor 
lying  upon  the  aorta.  The  cardialgic  attacks,  so  pronounced, 
and  of  a  character  so  similar  to  those  which  occur  in  ulcer, 
seemed  to  point  to  this  condition,  but  the  entire  absence  of  vom- 
iting and  the  tolerance  of  food  seemed  inconsistent  with  this  view. 
The  remarkable  throbbing  and  the  systolic  murmur  suggested 
aneurism,  in  which,  also,  there  may  be,  as  in  Stokes'  celebrated 
case,  the  most  intense  paroxysms  of  pain,  but  in  the  absence  of 
a  positive  tumor,  throbbing  and  a  bruit  do  not  suffice  to  establish 
the  diagnosis  of  aneurism. 

Dr.  W.  L.  Morris  has  kindly  furnished  me  with  the  notes  of 
the  case  subsequent  to  my  visit.  -On  the  evening  of  the  13th 
he  had  most  excruciating  pain,  lasting  two  hours  ;  no  vomiting. 
On  the  14th  he  vomited  in  the  morning ;  no  gastralgic  attack. 
On  the  loth  he  vomited  two  quarts  of  thin  fluid,  in  which  there 
was  a  blackish  sediment.  On  the  16th,  vomited  a  great  deal, 
.b'or  the  next  week  he  had  repeated  attacks,  bringing  up  dark 
material  like  altered  blood,  and  passed  dark  stools.  He  gradually 
sank  and  died  on  the  24th. 

Autopsy,  twenty-hours  qfter^eath. — Skin  blanched ;  much 


Ece  to  establish 


TObcutaneoas  and  omental  f»l     tu  >,     . 
1^«  -nitral  carina  ali.t    th  „te J'd  .^.'?  ™  """-^  '"-i  »»ft- 
'b.ckened  about  the  corporritam       Th''''  ""''"  °"'P»  "''» 
™noed  alherooatou,  !h,u,TtL-  ?',  '""'  P™""'"'  ^d' 
b™»chea.  TbeabdomiM  aoftewr        "V"  """■  ""''   "» 
"eg-lar  projection,.    The T„l™        7"/''™''' ^^  "™«™» 
Tbe  stomaoh  .a,di,.ended  .ir  "^       "'"'  ""  'P«^'"  <">«"««s- 
•f  "ark  fluid.    tZtTj'lT'  °r'°'^  "•»'"  «   '■"' 
"•.ngea.     Dnode„„„,  half  r  '  ifV  ™  i!""'''"''' '  ■">  °*er 

base  formed  partir  bv  hp»H  !f        '"'M""*'-  P'ece  (.3  cm.),  the 
;  »-«»Ul  tie  J.   l^^'^^l  P-J'  '"^  parti,  h,  thickened 

P«.ore.tico.d„odenalarter7wlT        °  '°  ""' "'  "■«  '"P"™' 

T^-^aa  thicteni„;tr.t   ~dtfte    "~"'''^ 
•"bjacent  tiaaaes  were  matted  t^getheV  '"°"'"'  '""*  "» 

sr^oH'tra:^  -4  "teXilTeCa: 

after  taking  fooa.    la  intj^VL  "  '"l'" ''^  ^°"" 
penoda  of  freedom  from  the  attacks     Th.^°  °"'^.  **  P™'''"^"' 
I'om  gastric  alcer  is  rarelv  possible  .,1   ^"^""^  °^  ''""'''^»»' 
features.  The  gastralgic  aJtaT  ^c'„    in   ^inT  "Vl"™"" 
jears  appear  to  he  more  common  in  dTodena  ,  "'  "'"^ 

Ibe  symptom,  I  believe,  which  led  .  ")   ^       ''''°' ''"'' "« 
oboioian  to  make  the  diagnosis  in  ht  iT^"."''  ^"■"■-" 


lanched ;  much 


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more 
ng  to 
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which 

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ments 

lented 

iscles, 

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ations 

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obser- 

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\VmKhTmder  Medicin,  Kog.  U  and  24   JR«^ 


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Jiuto'"S''j  tu>e7iti''hotirs  o/fter  death. — -Skin  hlanched :  mucti 


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ss 


MALARIA.' 


ifesting  the    blood  has 
low  that  certain  of  these 
y  distributod  and  more 
the'spirozoa,  and  to  tho  nematode  ann  tro,«.*i '"''*''''*  belonging  to 

beenLpwn'to  occur  in  ^hr^ood  of  vSfan'im'ir''^'%^°-"« 
vostigations  prove  that  the  llaffolkto  nmf.-?      aniraala.      Recent  m- 

blood.parasitL,  .nd  it  is  posX  Ua'ttrmay  be°th?  "Zr^^'^ 
organisms  of  certain  diseases.  I  propose  in  thi  .!.  pathogenio 
give  an  account  of  the  htemato/oa  whPr},  Ka^  k  ''?""nunication  to 
suffering  with  the  various  forms  of  malaria  '  ^''"  ^""'^'^ '"  P"'"'"^ 
desf;irdi^°f-.^X'1^^^^^^^^^  i  am  about.to 

'^rialfevers,  published  in  1884^'  He  found.  "^^^  '"?''.  °?  *h«  »»»- 
; ,  the  blood  oT  persons  attacked  w,■^^,^n„V    •'  »?  °baractenstic  elements 

^odies,  (2)  pig^erterboSln'tTntrioV^o  ''tr  r^^^ 

which  underwent  chances  in  form    dn.irJKo  i  ,"?,  corpuscles, 

pigmented  flagellate  organism    Tlwse  formic    "i  ""P^^id  ;  and  (3)  i 

jprpu.cf»  to  which   th.7  Sv.  S "me    Pkl^r"  °'  ","  ?'' 

red  corpuscles  in  cases  of  "comatn»o  T,nr„;l-  r  '^*«"or  of  the 
appear  to  be  included  L  a  hya h?e  mlCaSfr'.''  >\^'^''='» 
and  Celli,  and   Councilman  rwhnV,?^  I'  ^°<=°™>''g  to  Marchiafava 

*^ortjcAn(^jdcriV/edici»,  Nos.  14  and  24  Iflfi"! 


0      .  i 


'* 


.hlM 


i  f 


M- 


mm. 


■di^^iM^ii^MSAJ^  ^ 


Autopsy,  twenty -hours  qfterjieath. — Skin  blanched  ;  much 


1 


Lt%\/i 


AN    ADDRESS 

THE    II.EMATOZOA    OF   MALARIA.' 

huTiiatozoa,  as  thev  aro  calln.l  Tm  ^'''"'".V,'"'"'  ''"*'  certain  of  these 
important  than  wo^  had  h    Lir?    Z^^T' v'''''':'''t  ^'^  ^^- 

hesn,rozoa,anato  the  nen.atode  anrtromatlrw  "'  ^'''^°"«'°?  '" 
boon  known  to  occur  in  tho  blood  rff  vor?  ■  '^?"'^'  ^"V"  'ong 

vostigations  prove  that  the  ilaSfnLT"'  '""","''^-  R"™"*  in- 
blood  parasitU,  and  if,  .  nos  Z  t  °  f^  H  '°'  "'"  ^''°  °'"  "ncominon 
organisms  of  certain  ai.eS  I  topo'i":hi '°  '^'  I'.''''"'««"'° 
givo  an  account  of  the  hieniato/oa  wh  -h  >,  u  ^  communication  to 
sulForing  with  the  various  forms  of  ma  aHa"  ^''''  '^"""'^ ''»  P'"'«°°« 

Historical.— Onr  knowled™  of  ti,o  1 1  i  ^. 
doscribe.  dates  fronrthe  resear  ho^of  fe'v'^ir^-^  {^"^  "'^""^  *" 
wore  communicated  to  the  Paris  AcadomvnfM*r'"  ^^^""^'  ^^'''^ 
1882  and  which  were  finalirombodiod  ?i^  °u^^"'^'"°?  "'  ^^^l  and 
ariaf  fevers,  published  in  188^  Ho  found  ,1  f  T""-"?  ^^^  '^^• 
m  the  blood  of  persons  attacked  with  maS  7,f  """^t^'ptic.olements 
bodies;  (2)  pigmented  bodies  in  the  iSoV^ nf  .,'''" V' I''8'"''°t«'l 
which  underwent  changes  in  form  drrr?h„  i  *^^  /"'*  corpuscles, 
pigmented  flagellate  or/anism/TTeseforms^^^^^^  ^T^""'^  '  "^^  (3)  a 
m  tho  development  of  an  infusoriaf  n/J^n,-     ^?-\^'^,"P°'^  »«  Phases 

the  germ  of  tEe  disease      S:?d3'^eonTmoTthesf^  "f-"^"*^  »^ 
more  general  interest  in  the  niin-Hnn  ^„  ,  ?^  observations.     A 

of  Mirchiafava  and  Sel V^  who  VundT\tt  l*'^''.  publications 
patients  at  Rome  the  bod  es  descr  b«H  hi  t  ^^°°'L?^  malarial 
carefully  the  alterations  of  the  oTan'sm  fn  fc"?-  -^^7  «K«red 
corpuscfos  to  which  they  gave  the  nam «  pi  "*'?•'"  °^  "'«  '«<* 
Councilman,  of  Baltimore  harmnrnL.^  Plasmodium  malarife. 
vations.'  The  pigmo^rgmnulorso  numoro^  ^  •  °1™?'*  *^«««  "^ser- 
red  corpuscles  in  cases  of    '"pnn,,f.  °"^"*  *^®  '^t^rior  of  the 

appear  ?o  be  incl^deT  n  a  hya Ce  iPrr'^'/^'^^-'^r'^  ^^''^ 
and  Celli,  and    Jouncilman  /wlfn^,??       '  *<'°0!'«J'Dg  to  Marchiafava 

J /ortscAriWBrfcr  JlMictn,  Nos.  U  and  24  Ififi? 


IN 


clumps  or  in  rouleaux  It^irwel  Ito  sn  rn!^?,5  °°*  nggregatod  iii 
if  the  examination  is  Drolonir  ^  ''^"°"i>d  the  cover  with  paraffin 
added.     Cover  ilLp?paratbi  n^avT°'°*/^  ^^^  ^^"'^  ^^^^''^  be 

Description  of  thk  Bodies 
scattered  loosely,  but  are  encCrHr,  !^L  ,  ''''*'°°,  **"**  ^^^^^  *^«  not 

in  the  int.ij'^"^::^^i^i:^^;!y^^^i^^ 


no^ll^ryTat  IXd  ^"ett'tlt"'  "^  r^,°^*-  P^^"  "-« 
number  of  corpu.cfe's  sraffe  ted  vanSxtLri°"^'1-fr'^''"«-  ^he 
In  some  instances  they  are  readUv  fom?,1  ft  ^^^^ '''  difFerent  cases. 
or  two,  but,  in  other  cases  rrroW.^  ^"''  •*  ^^^''cl^ofa  moment 
sary.  Only  one  is  usi-aCpVeLrt  feh  '^^'"'°?tion  may  be  neces- 
or  even  four,  may  occup/the  stroma  ''°i'=°7"««l«.  but  two  or  three, 
smaller  ones  not  occupling  a  £70?  th«  ^  ^^ry  greatly  in  size,  the 
ones  may  almost  fill  A!  A  delicate  contnn,  r^''"'^''  ''^"«  ^^e  larger 
separating  the  body  from  the  stroma  »lf  ^'^l-'^^'^  »«"a"y  be  seen 
part  cularly  if  the  illumination tvery  brifiliT''  T^ ''  JV  ^°'^'^""^'' 
hyaline,  or  very  finely  cranular  nT^T+i!i  ^-  ^^e  substance  appears 
irregularly  in  il  Th  Jy^ay  be  Very  nSZ^'"'*  f  "'-"^  are  scarred 
to  the  body,  or  they  may  be  scInTr  Th„  "'^  ^""^  ^T'  ^  "^^^^  aspect 
Brownian  movements.  Occasionallv  a  ...  ^ /'■''l"'*'?^^^  P^^^^nt  rlpid 
terior  of  the  body.  In  severaHnSL«JtS''°^  J^^^  ^«  «««°  '"  the  in- 
closed  ina  cIearspace-vacuo]e-S  tCtri^  *"  ^e  en- 

are  more  or  less  spherical,  but  as  alreadvTf** ,  YJ''''  ^^^  ««e°  ^^'Y 
-^stinct.    The  pignientVa^fr^jt^S^atS  p^^^J;: 


the  blood  'Irop  ia 
examination  is  made 
rter  the  friction  and 
apparently  trivial, 
all  particles  of  dirt, 
ntod  bodies.  The 
'  thin  and  uniform, 
not  aggregated  in 
;over  with  paraffin 
ly  kind  should  be 
I  stained  in  methyl 

acid  preparations 
ay  bo  seen  with  a 
3  satisfactory  study 
•mly  worked  with 
im.   of     Reiohert. 


orpusde.—{a)  The 
il  patients  is  pre- 
corpuscle.  The 
attracted  by  the 
:arefal  study  of  a 
that  these  are  not 
^r  or  hyaline  body 
ed  discs  in  which 


ihes  were  made  «t 

often  paler  than 
Bss  shells.     The 

different  cases. 
fch  of  a  moment 
a  may  be  neces- 
)ut  two  or  three, 
satly  in  size,  the 
while  the  larger 

usually  be  seen 
very  indistinct, 
ibstance  appears 
Qs  are  scattered 
ve  a  dark  aspect 
ly  present  rapid 
3  seen  in  the  in- 
peared  to  be  on- 
1  first  seen  they 
outline  may  be 
•  theij  position 


in  relation  to  each  othnr      if  ♦!  „ 

served,  slow  changes  can  be  seen  S"  °^"'°  ^ody  is  carefully  ob- 
tjons  in  shape,  fhese  movements  ?vh,Vlf''!?"*"^^•"?S  ''^°"t  "^'tera- 
charaotcr,  can  often  bo  traced  wifl^  .  ^''I'®'*'"  ^°  ^^  amceboid  in 
sented  at  Fig.  i.  and,  be  'stiH  at'/L^'r^,  '^^^^  "•'«  ^'«»  4re" 
the  body  ,n  the  corpuscle  rcsu  t  frm^'  ^l  '^^^"«<=«  '^  Position  of 
slower  than  the  amoeboid  movement  of  L  .„7-  ,  ^^'"^  ^^«  ^'^^'^^^i 
not  seen  any  evidence  of  migrarn*  toX^:^^,^^^^^-,!^  'p^ 


U- 


^"-,iz?i:f. ;;.:,  Js—'M  >~iy 


TsiiiS!FSS'*^v\>;:i  ?Ts:niSS£i  Sli 


slow   altoration.s  in  outline,  .and    ii."  'i'^T^^'^servation. 


daucinK  nuitiun.    «i,  12  ] 
Us  shape,     w",  12.30.     a 


,  12.40. 


'     -  1  o'cfock;    a^  1.02.'  '''"  ^'  "'tered 


parations  these  bodies  stain  deenlv  wifi,  „    .• 

and  present  a  granular  stroma,  in^'^S\Cnr  ^1°'^*  °^  '""''hsin. 

bedded.     (Fig.  3.)  '        ^'"'^'^  ^^^^  P'gment  grains  are  im! 


absenceofpigmentand  n    he  ;u^,"^'''?^'*''J"^t  described,  in  the 
Fig.  .  illuitr^atcs  the  ^V^s^c^^ ZSZ:Z^!^:j^t'^l^ 


%.  .-.Ueteues  - '^^---^-^  .™  oT  ..1^  ,L 


) 


I 


r 


r 
) 
i 
1 

C         ! 


I,  at 


ilA 


bodies  are  devoid  of  structure,  and  the  corpuscles  in  which  they  are 
Lvf  °.  Tru-  '°  f^\^^  ^^°.^°  ""'^^  t*^"  pigmented  forms.  Marchia- 
tltJ^f  ^^'\^^?  have  given  an  excellent  plate  of  these  bodies/ 
regard  them  as  the  initial  forms  of  the  pigmented  bodies.  One  does 
occasionally  see  appearances  indicative  of  commencing  pigmentation, 

fn  fbr«L.''''  Tb  "'  "  '•"1"',*^^^?,^''^  ""'i"""^  °f  tl^«  pigmented  bodies 
In  three  cases  I  have  seen  the  following  remarkable  changes.  The 
hyahne  body  while  actively  changing  shape,  suddenly  burst  from  the 
stroma,  and  disappeared,  or  formed  only  a  few  granules.  Thus,  in  a 
red  corpuscle,  there  were,  at  3.40  p.m.,  two  hyaline,  irregular-shaped 
i^  'w  .1^  TT  <=^J.^°?'"g  '•'^PWiy  in  outline:  Th^  altemtions  ^^4o 
so  marked  that  t^ie  physicians  present  at  the  time  had  no  dillicultv  in 
seeing  them.  The  stroma  of  the  corpuscle  was  of  full  colour.  ^ At 
d.50  r.M.,  as  I  was  carefully  watching  these  forms,  the  corpuscle 
suddenly  ruptured,  and  gave  exit  to  two  distinct  masses,  whicrou  S 
broke  up  into  ten  or  twelve  spherical  bodies.    No  change  took  place  in 

The'sfrn^'.  r/r  ^°'"'''  T'l;'  ^^'*  ^^"^  ^'"''^'  P^^^  ^^^  indistinct. 
Ihe  stroma  of  the  corpuscle  became  quite  colourless.  On  two  other 
occasions  a  similar  phenomenon  was  witnessed,  but  in  one  no  trace 

.ttl^'  ''i°T ^l -^f  !f '^^''^  '""^f^^^-  This  is  evidently  a  physical 
change,  and  I  think  these  very  pale  hyaline  bodies  must  be  carefully 

STeKrlX^'o;n^e^"'  '-'''''   ^'^-^'^Po-iblyaasociatel 

J^Llj'o  '  m7  f'^'  ^x^T  ^T  ^*'"°^^«  '"  'he  red  corpuscles  con- 
tainmg  soxid-looking  bodies  of  various  sizes  and  shapes.  Certain  of 
these  structures  resembled  micrococci  very  closely  (Fig.  C),  and  stained 


Fig.  5.-Cever.glas8  preparatioTi,  showinp;  cnrpusole  with  solid,  deeply  stained 
boilies  111  small  vacuole.s.  =«•■■«.« 

Uralj  '"^  ^'''- '°^  *^r'  '  ^'"*  "^^'''''  °^'<'n  Jn  tli«  same  corpuscle,   wore 
larger,  more  irregular,  and  altogether  different  in  appearance  (Fig  6  5 


^'^"inmitlil'o^'  Yf\  '■""'^  *"""?'  '"  t^'  ">'<"■'"'•  "f  vacuoles  (?)  which  alter 

^.!l^^*"/^!'  """^^  ""^'^  "'"""y  ^^S^^y  refractile,   and,  when  two  were 
hf L  ."■'r^'^VP,^''^^'*"'^',  «"gg««ted  a  diplococcu  .     In  three  insU 
l™  h*^]''  ^*^  \^''P  ^'^'"'  *^°''  "«  '»•  composed  of  pigment      Tie 
larger  bodies  were  homogeneous,  very  variable  in  si/e  and  shTne     No 
ZIZ?'  ^^^'^^''^^d  in  them,  but  the  outlines  of  the   lucSn  whS 

vSy  SnZt  and  forT*"  T'^^'hu  ^°  ""^  ^'-  '^^^^  Oodles  -,; 
the^corpuscles   """^  ^"^  ^^^^  formed  the  only  noticeable  alteration  in 

we?;  f^tdYn  SlT^'*^  Pigmented  crescents.  These  bodies,  which 
rnceandstrm.h,r?  TV,  'T''  P'-«'*«nt  remarkable  features  in  Appear- 
cent  S  7?  wi?i"  ',  ^?'"'  wasu.sually  that  of  a  beautifu  cres- 
cent  (lug.  7),    with  rounded  or  gently  tapering  ends  ;   but  the  degree 

7  ForUchntte  dtr  Madicin.    18S5.    No.  24. 


n  which  they  are 
forms.  Marchia- 
3  of  these  bodies/ 
Dodies.  One  does 
^^8  pigmentation, 
pigmented  bodies, 
jle  changes.  The 
Illy  burst  from  the 
ules.  Thus,  in  a 
),  irregular-shaped 
le  alterations  were 
ad  no  dilHculty  in 
f  full  colour.  At 
as,  the  corpuscle 
ses,  which  quickly 
vnge  took  place  in 
le  and  indistinct. 
On  two  other 
in  oue  no  trace 
dently  a  physical 
must  be  carefully 
lossibly  associated 

1  corpuscles  con- 
apes.  Certain  of 
ig.  6),  and  stained 


lid,  deeply  stained 

corpuscle,   were 
loaranco  (Fig.  6.) 


=  ^\ 


les(?)  which  altor 
containing  small 


,  when  two  were 
three  instance.s 

■  pigment.  The 
and  shape.  No 
B  spAces  in  which 
lese  bodies  were 
ble  alteration  in 

se  bodies,  which 
tures  in  appear- 

■  beautiful  cres- 
but  the  degree 


more.  Thoy  ,„  „„i  ,tt„i,„j  .„3  ,K' °' '  ,'•''  '"PmsU,  ,ometim,a 


a,   ^ 


a 


^  ,c^ 


""'■'■as  sfeed"I?'^'.'/o;  l■a4^af,'d^^,J'i^  f^'^^'T^,  ">  *»"=  form  of  the  pigment 
sometimes  present  in  the'concave  side  '^"""^  ^''^  """"^  meSbrane 

(F^gTr^hTbry  irthr^rea^t  ateT  °^*^«  «  -^S- 

ess,  homogeneous  material,  L  the  cen^r^ofwlT.,''-  "^  "^^  ^*'"<=ture. 

ection  0    pigment  granules.     This    with  tb^n    '  v"  P'jn'ii'ent  col- 

these  bodies  very  easily  recognisable' in  the  blnn^""^'"  ^1™'  '""kes 

surrounded  by  the  corDusele^     Thi  i-         ..^'  ^"'^^  when  closelv 

distinctly  graLlar.l^d  varies  ieXTn  t^^  ^"''^  '"^  ''"^l 
rule,  It  18  central  and  aggregatX  J/w"  '^V^angement.     As  a 

form  of  a  band  placed  trKrsefc  ?o  Z  "  *  ^f  P^  ""^^"'"e*  the 
some  instances  it  is  more  scatte'erbSt  iLT^  °^  ^^^  <='««<«°t-  In 
end  of  the  body.  Although  the  VosJ  care?,7«r'  ?''°.  '*  »*  ^'t^^^ 
detect  any  movement  in  the  hyalinTsubstan/^nf  .if'"'°''"°°  ^^'^^  to 
existence  of  such  may  be  infe^rfiT  fr„T  A  "  "^^^^^  crescent,  yet  the 
which  the  pigment  yanutunde?  ^^^i^T  P°«>«-«  ^ov^emen? 
these  alterations  ;  changes  in  form  Ife'pri^;-  ^'  ,?'  *'  "'   represents 


Fig  8.- 


.  and  6  show  (s^scents  in  the  fntertor  nf  tca  » , 

changes Tn  a  cresMnt     ^  '=°'T««<=''"'  J  1,  2,  .nd  3, 


Sketch  1  was  made  at  9.40  2  af  in  m  j  „ 
outline  of  these  bodies  is  very  clear  ^nd  d«f  I  ''V*'-3°  ^■^-  The 
and  rounded  forms  of  identical  stracture  ar«  ^l"^'  ^1°'^'  ^^^^E<^t,l 
crescents  predominate.  The  numW  ll«,^'n ^'^'^^t  ^itli.  but  the 
ashde,  to  six  or  eight  in  the  field  of  the  rai"'-  ^'°^2"«  °^  t^"  ^^ 
always  free,  they  occur  sometimes  in  tb"«-V"-  though  almost 
•'•?^?'**J°g'/'''jbtle8s.  the  mode  oTdevlSen^^  «  «on>uscle. 

(p)The  Rosette  Form In  six  \n^i^^nl^^^     ^^^^'  ^>  «  a°d  b). 

a  little  larger  than  red  corpuscles  wShn^-.™  ^''^  ™"°'^«d  bodies, 
and  in  the  centre  a  rosettr^f  p'il^^  J^.^'^  g^^S"!"  Protoplasm 
reared  to  be  eaclosedjn  .  deliff  rmSe?  Vi^efe  fr  i 


Fig.  9.-.Ro«ette.rom  =  1  free ;  2  within  t^.e  .heU  oU  red  corpu^^ie. 


i-> 


^    ' 

w  ^i 

•I  ; 

'   ^ ! 

vl?       > 

■  (^ 


;         I 


'r 


li 


! 


hi 


,1 

J  -l^jly 

;           s 

t  mm 

SmI 

II J 


^'  ^ 

1  ' 

»• 

w. 

' 

i:  ^  P^^  ' 

segmentation.     Ihua  Fig.   10,  a,  represents  one  of  these  as  seen  at 


1^0  <S)  ^>g>t 


& 


'©& 


© 


a 


Fig.  10 — Segmentation  of  a  rosette-form  •  n  of  «  „         ,     . 

t.o„^procaeaing;    c  6.30.  ^'^J^^io^  ^Ji^il^  t^^^'^^^^ 

'4'^'en&t'Ltt4l'Z^^^^  '^-"-t  -dications  of 

resulted  in  the  formation  of  A  «wt  P'^Sl^P'*^^^-  ^t  6. 30  (c)  this  had 
about  the  centrlrpSent  and  ^^'''  -  '  °^  •°'"''-  '^'''^''^^  '^''^^'«^ed 
(^)  the  shell  had  bSand^f^e^^^^^^^^^^  ^^  7.40 

presented  a  tiny  speck'at  or  aC  the  centre  At  0  iT.^^^'l  ''^'"^ 
undergone  any  material  change  n  Case  gO  tne  of  ?  n^7  ^'^ ''°* 
this  phenomenon  was  repeatedly  observed  The  d«v/i  ^^'^^I"  ^.8^' 
rosette  form  can   I  thinlr   v,o  ftn„„Tf      ^;-    -f^ie  development  of  the 

bodies,  whichTrIc  eas  tn  si  J  mtflSe'^entlre?'"'''"^'*-^  ^'^'^''^'^^ 
some  instances  the  body  was  rarroundP,rLfr'P''''^°  '"^^^''^-  1° 
corpuscle,  in  others  ther^e  was  no  trace  of  l^  *^^\^«°»."^'>t  «/  the  red 
gradually  collect  in  the  centre  of  thf  L^L  •  ^^^  P>gment  granules 
rosette.  I  thought  these  cSn<.P.  £?^  J?^ '"  a  m„ro  or  less  distinct 
on  this  subject,  but  I  findThat  GoS  l?n»  •^^«^'°°'^«'l  by  the  writers 
tion   of  them,   and  ha    boautiS^fi  J.»i  l'^'^"  ^f^  ^""^^  '^'^^crip. 

LivtSs%a£r7n"S";SBd"  *"^-"  ^T?.^^"'  '^^^  ^  «-*  -"^ 
scription  oi^che  ciliated  bfdiVs  If  ^^  ''^f  ^^ulity  more  than  his  de- 
trary  to  all  past  experience  that  f  ITf  '°  '"^Probable,  and  so  eon- 
the  blood.     The  S  of  th«  ni/   ^    ''*\?'^r''^  in 

on  the  folly  of  a  rcentidsm  1if„H  ''''  '"°°'^'>'f  *''"g^*  «»«  *  l^s^on 
preconceived  notions  drawn  f^^  on  theoretical  conceptions,  and  of 
bodies  were  seen  n  seven  r.iT  '^  ^J'^^'^'l  .^^Perience.  Flagellate 
one  or  two  in  a  shde  Thnf '  '^''  JP  ^'l*'  numbers,  usually  only 
often  not  more  thtn  half  the^s?^'!  '7^11  '^*°  •'^^'^  Wood-corpuscles^ 
in  one  diameter  to  a  red  rnrn ,  ,  }  ?P«''™en  in  one  case  was  equal 
ovoid,  orpearshaned  the  nrS'  ^^'r^  T^'  ^*-  ,  They  are  round, 
instance  contaS  pi^t^  ?S^      hnely  granular,  and  in  ever^ 

rapid  Brownian  1?SSVf"  ^^^^^Tir^'n^'^'n^  often  displayed 
uvemenis  ti<ig.  n).     Tlie  Qagella  are  variable  in 


ThSenVth"?,'  o^'?'  "''^  fonr  were  noted  in  dilTerent  specimens 
that  of^fJ;  Z^\r%^!J?^\^'  «««'".-t«4.  was  two  or  th?ee  time; 


that  of  the  hnHv     tC„  Bstunaiea,  was  two  or  three  times 

*  Sulla  Infezioue  Malarica,  Arohlvio  per  U  Scienz, Mmol^i;^:..  m,  4,  imQ^ 


of  the  nature  of 
;hese  as  seen  at 


t  G.IO,  segmenta- 
'■40,  small    free 

t  indications  of 
.30(c)  this  had 
Jodies  clustered 
eath.  At  7.40 
rpusclos,  which 
0  they  had  not 

quartan  ague, 
opment  of  the 
ular  pigu.ented 
0  is  tilled.  In 
lant  of  the  red 
jment  granules 
>r  loss  distinct 

by  the  writers 
:y  full  desorip. 
ipment  of  the 
.     He  has  fol- 

detail  than  I 

len  I  first  read 
3  than  his  de- 
le, and  so  eon- 
aould  occur  in 
ht  mo  a  lesson 
ptions,  and  of 
J.      Flagellate 
,  usually  only 
od-corpuscles, 
;ase  was  equal 
ley  are  round, 
and  in  every 
ten  displayed 
'6  variable  in 


t  specimens, 
r  three  times 
tly  tapering, 
(xistence  of  a 

No,  4,  1886. 


small  terminal  knob,  figured  by  Laveran.     The  movement  iS  exceed- 

rtttdrivrfwiv  .  "^'°«  o/  the  W  filaments  may  be  sulStf; 
strong  to  drive  away  the  corpuscles  m  the  vicinity.  The  undulatorv 
movement  caused  by  the  play  of  the  filament  over  the  surface  of  a 

fees"'the  cnr'Thl^lr'^'l  '^' '^''r'^'^^.  "^  the  observer  before  he 
sees  the  cilia.  The  motion  does  not  persist  long;  in  none  of  the 
specimens  which  examined,  for  more  than  half  an  hour  In  one 
instance,  the  llagella  disappeared  in  the  short  interval  between  two 
observations,  but  I  could  not  determine  what  became  of  them,  I  have 
not  seen  the  free-swimming  cilia  described  by  Laveran,  but  Dr.  Conn- 

beeT  abr«  ^o^^r  ^^''  ^'-^^  '°°'''f™'"^  ^^''  observation,  I  have  not 
been  able  to  d  scover  either  nucleus  or  vacuoles  in  the  flacellate 
organism  Slight,  irregular  changes  in  outline  occur,  due  to  slow 
movements  in  the  protoplasm. 

(ri)  Small  round,  pigmented  bodies,  from  one-fourth  to  one-half  the 
size  of  a  red  corpuscle,  were  not  uncommon  in  some  cases  (Fig!  12) 

%D     S 

Fig.  12.-.SmaU   free   pigmented   bodies,    some   of   which   show   amoiboid 

movements. 

Usually,  they  remained  unchanged,  but,  in  several  instances    thnv 

SeT.^Jl^T^?^'^  movements  %he  smaller  onesTbout  equ  'in  siz^ 
the  products  of  subdivision  of  the  rosette  form 

laHof  7£nrv,r'n^  *°/"f"^,«  tl^e  '^'^tu'-e  of  those  bodies  and  their  re- 
lation, I  will  brielly  refer  to  the  conditi«n  of  the  blood-corpuscles, 

alrldv  dicrZr  Th'^""'''^  "?  f''"  notable  alteration  save  that 
airea  ly  aescribed.     The  pigmented  organism  evidentlv  destroys  the 

Zf'Xf.T'-'T'^'^r?.^^'^'''''^  t^«  aflected  eel  become 
pale,  often  spherical    and,   finally,   are  reduced  to  the  condition  of 

mere  shells;  except  m  cases  of  pronounced  anremia,   the  variations  of 

the  corpuscles  in  sue  and  outline  were  not  great.     The  colourless  cor 

puscles  were  in  some  cases  increased  in  number,  and  in  very  many 

instances  contained  dark  granules.     In  several  specimens,  they^ere 

observed  to  contain  the  pigmented  organisms.     In  Case  40  a  creslent 

had  been  included  (Fig,  13).  and,  in  Case  51,  the  process Vinu   on 


Fig.  13.— A  colourless  corpuscle  containing  a  crescent. 

?Fi^^°if''^%re"'^'^,  ^°'^'^'  ^"^  ^^^''^^'l  "ii^Dg  h^lf  an  hour 
[iig.  14).  The  blood-plaques  were,  as  a  rule,  scanty,  even  when  the 
anremia  was  pronounced.     No  pigment  was  seen  in  them. 

Types  of  Malaria  Studied.-Oi  the  seventy  ca^os  examined,  a  ma- 
i^H  -r  "I-'®  '"^'.^l^f «  of  ordinary  intermittent  fever,  chiefly  quotidian 
and  tertian,  with  two  quartan  cases.  There  was  one  case  of  remittent 
tever,  one  of  comatose  pernicious  malarial  fever,  «nd  the  remainder 
were  cases  of  malarial  cachexia  or  chronic  paludism,  with  occasional 
outbreaks  of  fever,  with  or  without  chills.     In  all  of  the  cases,  with 

found  iShTbkor^"'  °°^  "'  °*^°''  °^  *^^  ^°''°''  ^^°^^  described  was 

matim  of  the  Forms  to  the  t^arieties  of  Malar ia.~Tho  pigmented 

Zf^'^  K*"^' M  r\  ""'*  ^''^  i"^  ^"^^  '''^'ite  and  chronic  caTs.  but 
tney  may  be  said  to  be  specially  characteristic  of  the  more  acute  mani- 


f  . 


(  i 


^1 


!i 


t 


i      I,: 


1 


liiiilli 


s 

forms  were  almost  invariably  prei'rtir™.^''''^^"*''''-''^""'^^ 
detail  to  the  cases  in  whiTtLrZ^not  fZ^.^  V''\''''V-''''^y  '" 
pigmented  forms,  and  the  vlr^^Uo^Lf-  .»onnd.     The  hyaline  non- 

m  the  acute  cas'esTindeerthte  ttZ^  '°^"^  ^°^''''  *'«'""=^"r 
tions  noted  in  several  instances  Thn,  ?n  p' ""'o^  ^^^  only  altera- 
was  admitted  to  the  PhilSt'jo  w  '  K^^^T  ^^'  *  «»»"  afted  48 
chill.  HehadLiap^Svt?endfv?E'f'^  September  27th:  in  a 
malaria  several  jeavF^rSBlv  rll  ^!°^'  *"^  ^-"^  '"'^'^^^^  with 
hot  stage  showed  no  pigmented  bodies  b«t.°^rn*"'°"'''^  •^"^i"^  t^« 
toining  the  vacuoles  shf wn  in  FiS  5  and  6  tT^^^,  corpuscles  con- 
28th,  29th,  80th,  and  October  l«f.' .^5       v^^*'¥'*°''^""ed  on  the 

fully  examined,  wfthout  finding  othe?boT«^  .^"^  ^1'  ^^°.°'^  ^"^  <="«- 
oles  or  hyaline  spaces  On  O^tnCi  J.v  **•  *^*°  *^o««  i°  the  vacn- 
of  aninine  twiceWaV  4?ch  w  '  ooA?''  ^''}T^}>^g<^''  ""'^^  *«»  grains 
chill  after  October  7st     On  thl  5?h  lif°"*  '^"'"  ^^"  ''"y-    ^e  had  no 

numbers,  which  peSednntU  the  27th  "^^  ^t^•''^l"  *?'^ 
•mmation.  ®  ^''''«  "»e  date  of  the  last  ex. 

some  time.     OreigS  ^sesTn  wlvfflh  ''''"  ""''"  *^««*™«°t  '"' 
there  was  a  history  of  LfectknkstinJ^frn^'^- ''''■'  r^'"*'  ^°  *^«1'« 
In  many,  the  cachexia  warSkeda^/Z  ''',''''^'  *°  f'^  '^*"»ths. 
In  six  instances  the  aWack^  S  reclt-unlT«^'''ll'°^^^^^^^ 
every  one  of  these  cases  axiiniZ  ^.aI        .1^  *  "lonth ;  but  in 

crescents  occurred  alonTfnthrblo„d?K«.T>.  *'''''°-  ^'  »  ™'«'  th« 
in  which  the  pigmented  aracBSL^-  ^t'"  "^'^  •=»«««  "^served 
flagellate  organl^s  were  aTsfprltnt  i^M\Tf /T'  ''"^  *^« 
K^r*  ^^^^^  °^  -^-"tU^feverihtcirdtVb'eVnTnr 

cZ^:  aTXt"in"^to*cLtTof  •iLh'^tr"*^"^      -  -•- 

bodies.     Case  31:  tertian  a'^e  exam  n\  ■% °™'?''°''^  intra- cellular 
cine.     Case  33  :  quSan  for' s'en  days'"  Cas  Vr""''^  %"?  '"I'" 
SIX  weeks,  amx-mic,  and  had  a  large  sE  •  +    t       •  ^'^^^idian  for 
Case  39  :  quotidian  for  seven  days^  Casl  68  •  aSi^f '"'"^  """""/^y- 
for  SIX  weeks,  then  stopped  •  now  dafll -fifji'i  ^"°tidian,  on  and  off, 
quartan  for  three  weeks      iLIcZ..^JI^^'^K^°^  *  "^^^^^     Case  60 : 
not  been  much  stS' and  as  Got  '1*^'^?  ^f^^I'  ^  ^^^^  f«™  has 
important  connection  'with  the   ^fveCl^.'^'rl*"  ^'''^'  *»  ''  »" 
was  only  observed  in  acute  cases  whiphv,^«^f  l^  *'''  P^'oxysm.     It 
The  flagellate  organisms  w«r«^.       t^-  °°*  ^^'°  "'^'^^^  treatment, 
were  chronic  forms^^andTne  In  acute  .?»«  '?  .t^'"  '"'?'  «'^  "^  '^hich 

The  small  free  pigmented  boTi^        ^  *^''' "^"'^"^ 
they  seemed  more  affiant  in  the  chrjf.  V'^  ^"'^^^^^  >°  "^"^bers  ; 

Belati^  of  those  FoZTlthTpar^y^^^^^^  ""'^t''^^- 

were  made  with  a  view  of  determiW  w^'fT     I?  """^  observations 
any  definite  relation  t^  ?L  remSkabl!  Si '  \.'l  organisms  bore 
terise  acute  malaria.     For  thknntnnl!  P^"°'^'?  ^ttacks  which  charac- 
were  made  in  the  hitemls  of  in^Phff'  '"  ^^^J"^^  '=*«««'  e^^aminations 
paroxysm.     The  resS  may' T  hus  Jteted     S  ""'''  '"'^''  "''  '""^ 
particularly  if  recent,  in  which  tL»r^K^^        *^^''®  ^^""^  mstances, 
more  numerous  and  a°ger  before  1H^°''^  organisms  were  decidedly 
the  intervals;   there Tre  otC  in  wM^i? /f'  paroxysms  than  in 
chill  and  hot  stage  was  so  sman    f),J    "^  *H'  °""'^''  ^""^S  ^he 
find ;  in  others  a^inT  slides  tXn  bSl  ^'""Pir'  ^'^  ^^^^  ^"'^  *« 
stage  were  negative    and  vet  in   -1      ««  attack  and  during  each 
were  present  in  the  blood     I  tHnk'"^'T'°t  V'^^'^y'^'  the  bodies 
bodies  in  the  red  corpuscles  are  S«  n,  *'''  ^hoK**"**  t^«  pigmented 
attack,  but  the  diffeSTby^T  Tear TriSr  an"?  /=  re^ 


uotidian  or  tertian 
eboid  intra-celliilar 
fer  subsequently  in 
The  hyaline  non- 
bodies,  also  occur 
■e  the  only  altera- 
!8,  a  man  aged  48 
ember  27th,  in   a 
i  had  suflfered  with 
mined  during  the 
us  corpuscles  con- 
ills  occurred  on  the 
le  blood  was  care- 
hose  in  the  vacu- 
an  with  ten  grains 
days.    He  had  no 
icenta  intolerable 
ie  of  the  last  ex. 

ore  chronic  forms 
der  treatment  for 
>resent,  in  twelve 
M  to  six  months, 
greatly  enlarged, 
month  ;  but  in 
As  a  rule,  the 
e  cases  observed 
tte  form,  and  the 
3nd  the  crescents 
not  been  under 

occurred  in  six 
id  intra- cellular 
ttack  ;  no  medi- 

•  quotidian  for 
uinine  one  day. 
m,  on  and  off, 
eek.  Case  60: 
is  this  form  has 
I  ascribe  to  it  an 

paroxysm.     It 
nder  treatment. 
Bs,  six  of  which 
ks'  duration, 
le  in  numbers ; 
cachexia, 
ny  observations 
organisms  bore 
I  which  charac- 
i,  examinations 
t  stage  of,  the 
vere  instances, 
were  decidedly 
cysms  than  in 
ler  during  the 
'  very  hard  to 
id  during  each 
ns  the   bodies 
the  pigmented 
nd  during  an 
id  I  have  re- 


peatedly had  to  search  long  in  slides  prepared  during  a  naroxvsm  fnr 
a  single  example      In  acute  cases  whrchLvo  laSome  weeK  and 
have  had  no  medicine,  the  amcrboid  bodies  have  seemed  to  be  n'S 
as  abundant  at  one  time  as  another.     Nor  havo  I  hp«n  .hi»  *        ^ 
special  diffeionce  in  the  form  of  tho  boEs  jult  before  or  during  'th^ 

Sl    n  'u;"!,tmet.rt  InY  1 ""  ^"^""^  ^''^y  nia/be^mall""!^  it' 
rXred  fn^lho  »i     '   "■^'"J^'^  may  present,  as  in  Case  29,  already 

T).«  r  ^'  '^\ fPP«"'»'"=6  of  vacuoles  containing  small  solid  bodies 
«f,Tl    ■•emarkablo  segmentation  of  the  rosette  form  was  in   each  fi 

i  five  ?al"a  set?^/'^lP"°'y^'"'  ^""^  «°^«'  claims  to  havTtracei 

ague-an  attempt  was  made  to  follow  Tese  changes  wfthlhetlloT 

ZXt  for  S«r"'l*'  ^  l'^  °V'.'  ''''^  "^'^  maS,Tn  and  off:  for  a' 
year,  butfor  three  weeks  before  admission  the  chills  had  been  recirrin^ 

cT  n     Srr  ^H     °"  ^"^''^^y-  *^«  ^'^'  tl^«  blood  was IxaSd  in  hf 
J  li-  ^^^  '^^  corpuscles  contained  many  large  pigmented  hnHi«a 

o'LVh'Vtrand  sT rr  "T'T'-  --y  -  P-oStbdi^sfon! 

a'm^S^i^rtt^S^^^^^        rc/Ty  To^J^TlT:!!-; 

Fomented  intra-cellular  bodies.     They  did  not™eem  more  numerous 

On  the    o'thlL"^^'^-"''  TZ'  T^'l  °^  '^'  «■"''»  bodies  in   he  field 
On  the  10th  the  note  is  :  "No  free  bodies,  all  intra-cellular  tolerahlv 
numerous;  no  rosettes ;  no  segmentation."    On  tL  1  th  iaUx 
aminations  were  made,  and  the  note  reads,  "absolutely  noAe  lave  nig 
mented  forms  m  the  red."     On  the  12th  the  slide  at  8  fw  showe^d 

irrfngern7h«°/P»°i?'l>'"^'^^'  ^"'"^  ^^'^^  the  granules  irregularlj 
arranged,  other    with   distinct    rosette.      Fever    began    at  ll  a  m 

fo^°,"l''°"^*^^P'ryr'  hourly  examinations  werf  made  rosetl; 
the  ordlZw  °'^'°*'  """^  «^g«»e"tation  active.  On  the  13th  and  14th? 
the  ordinary  forms  were  present,  and  in  the  paroxysm  of  the  15th  thp 

Knnll  ^^^''l  ^'"  ^^"'"^  «««°-  The  de^velopCt  o  pneumoSl 
interrupted  the  observations.  It  is  worth  noting  that  in  this  carthe 
onset  of  the  par^'xysms  was  marked  by  an  outbreak  of  the  most  in 

Certainly  the  segmentation  seems  associated  in  some  way  with  thn 

The  crescents  appear,  as  already  stated,  to  be  confined  to  the  ir,nr« 
chrome  cases,  or  to  those  which  have  had  treatment      They  mavTer 
sist  for  weeks  or  months.     Thus  in  Case  56  -a  patient  had  SregSla^ 

montn---for  three  weeks  there  was  fever  without  chUls  the  temn«r<i 
ture  rising  on  some  occasions  to  103°.  The  cres^ente  were  numerous' 
and  were  not  associated  with  other  forms.      With  this  h^s^eneral 

mnrov«H '"''/?^'^'."'^  K^'^  °°*  look  anemic.  Under  ^^0 
bffilf.'  *°v  ^^^  f^:^^^^^ii<  but  the  crescents  were  stUlTn  hi^ 
blood  SIX  weeks  from  the  date  of  the  first  observation. 


i 
I 
) 
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I 
I' 


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A 

,1 


li 


i 


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ly 


10 

Genuine  paroxysms  may  occur  in  those  chronic  tasos  without  tho 
development  of  other  forms  than  the  crescents.  This  observation  was 
repeatedly  made  in  Case  25,  a  man  with  irregular  malaria  of  many 
months'  duration  and  occasional  severe  chills.  The  flagellate  organ- 
isms did  not  seem  to  have  any  special  relationship  to  the  paroxysm, 
but  they  were  so  rarely  seen  that  my  observations  on  this  point  are 
not  of  much  value. 

Inliuence  of  Medicines  on  the  Organis7ns.—Qaiaine  invariably  caused 
the  pigmented  bodies  to  disappear.  In  acute  cases,  which  wore  usually 
stud'od  during  two  or  throe  paroxysms  before  the  administration  was 
begun,  this  observation  was  repeatedly  confirmed.  In  a  few  days  tho 
corpuscles  wore  entirely  free;  in  several  instances,  the  crescents 
appeared  before  the  blood  became  normal.  For  example,  Case  46  had 
his  first  chill  on  October  1st,  and  a  daily  recurrence  until  the  10th, 
when  he  came  under  observation.  The  pigmented  bodies  were 
abundant,  and  continued  so  on  the  11th  and  12th,  when  the  tempera- 
ture rose  in  the  paroxysm  to  105°.  Quinine  (twenty  grains)  was  given 
on  the  morning  of  the  13th  (which  broke  the  chill),  and  repeated  on 
succeeding  days.  The  bodies  were  present  on  the  13th,  and  a  few  on 
the  14th.  They  were  not  found  on  subsequent  days.  In  less  acute 
cases  the  action  of  the  quinine  did  not  seem  to  be  so  prompt,  and  tho 
crescents  did  not  disappear  so  rapidly  under  its  use.  Certainly,  in 
secent  cases  this  medicine  acts  as  a  positive  specific  against  these 
organisms,  just  as  it  does  against  tho  malady  itself.  Arsenic  does  not 
appear  to  influence  the  pigmented  intra-collular  bodies.  In  a  chronic 
case,  without  chills,  but  with  irregular  fever,  the  crescents  persisted 
for  aver  five  weeks,  although  the  patient  had  improved  in  general 
health  and  vigour,  and  was  no  longer  ansemic.  Thallin  and  anti- 
febrin  were  given  in  some  cases  without  any  noticeable  results.  As 
is  well  known  to  practitioners  in  malarial  regions,  there  are  cases  of 
intermittent  fever  which  subside  without  special  treatment.  I  have 
had  several  patients  in  whom,  without  any  quinine,  tho  chills  stopped 
or  recurred  very  irregularly.  In  Case  66,  the  crescents  appeared  in 
the  blood,  which  at  first  contained  only  the  intra-cellular  forms. 

Case,^  examined  with  Negative  Result.— Aa  before  stated,  there  wore 
eight  instances  of  apparently  true  malaria  in  which  the  organisms 
were  not  found,  and  to  these  I  shall  now  briefly  refer.  I  would  re. 
mark,  in  the  first  place,  that  we  cannot  always  rely  upon  one,  or  oven 
two,  examinations  of  the  blood  for  these  bodies.  They  may  be  very 
scanty,  or  they  may  be  present  at  one  examination  and  absent  at  the 
next.  For  example.  Case  41,  a  young  man,  aged  26,  was  admitted 
with  a  temperature  of  104°.  He  had  been  cranberry-picking  in  New 
Jersey,  and  had  been  ill  for  a  week  with  fever  and  indefinite  pains, 
but  no  chills.  He  was  so  very  dull,  that  as  the  fever  persisted,  typhoid 
was  suspected,  although,  as  a  cranberry-picker,  malaria  was  first 
thought  of.  The  blood  was  examined  on  three  occasions  with  negative 
results,  but  on  the  fourth  observation,  five  days  after  admission,  and 
when  the  temperature  had  fallen  to  normal,  crescents  wore  found, 
which  continued  in  the  blood  until  he  was  thoroughly  cinchonised, 
The  cases  are  as  follows  : 

Case  10.  Child,  aged  5  ;  chills  and  fever  in  Maryland  nine  months 
ago,  occasional  chills  since,  the  last  two  weeks  ago;  spleen  4  inches 
vertical  diameter ;  had  taken  quinine,  none  recently.  One  ex- 
amination. 

Case  11.  Man,  aged  19 ;  never  malarial  before.  Four  distir-t 
paroxysms.  Slides  examined  from  ♦'fth  a»<i  lixth,  taken  in  cold, 
hot,  and  sweating  stages.  No  quinine.  I  did  aot  see  the  case  sub- 
sequently. 

Case  20.  Man,  aged  40.  First  attack  six  months  ago.  Chills  on 
and  oflf  for  past  three  months.  Blood  examined  throe  days  after  last 
chill.     Had  taken  quinine  for  two  days.     Spleen  enlarged. 


II 

Case  21.  Man,  agod  28.  Examined  on  17th,  first  chill  on  Sopteni. 
ber  6th  ;  four  since.  On  14th,  took  iiuiuino  grs.xxx,  and  has  had 
gr.x  t.  i.  d.  since. 

Case  26.  Man,  agod  35.  Chills  for  three  weeks,  at  first  quotidian, 
latterly  tertian.  Had  taken  medicine,  but  did  not  know  the  nature  of 
it.  Was  admitted  on  2Uh.  Two  examinations,  negative  ;  pigment 
in  white  corpuscles.  On  25th  quinine  was  given.  Three  subseriuent 
examinations,  without  result. 

Case  28.  Man,  agod  60.  Admitted  on  14th.  Well-marked  chills 
for  cijj'ht  weeks  ;  had  one  when  he  came  in,  and  four  after.  Hlood 
examined  on  28th,  two  slides.  He  had  had  quinine  gr.  xx  each  day 
since  admission. 

Case  38.  Man,  aged  70,  resident  of  the  almshouse  for  six  years. 
First  chill  on  2nd,  second  on  the  5th,  third  on  6th,  when  blood  was 
examined,  two  slides. 

Case  52.  Man,  aged  25.  Chills  and  fever  for  six  days.  Blood  ex- 
amined  in  chill,  and  on  the  following  day.     Had  had  quinine. 

Thus,  in  five  of  these  cases  auinine  had  been  taken,  and  they  may 
be  counted  out.  In  Case  10,  the  child  was  brought  from  the  country, 
and  only  one  examination  was  made.  Case  1 1  was  undoubtedly  a  case 
of  quotidian  ague,  and  the  examination  of  slides  taken  from  each 
stage  of  the  fifth  and  sixth  paroxysm  was  negative.  I  did  not  see 
the  patient,  and  further  examinations  were  not  made.  In  Case  38, 
the  bodies  were  not  found  on  two  occasions.  This  man  also  could  not 
be  followed,  and  I  do  not  know  his  subsequent  history. 

The  importance  of  excluding  other  causes  for  the  paroxysmal  chills 
was  well  illustrated  by  a  case  under  the  care  of  my  colleague,  Dr.  J. 
H,  Musser,  which  we  regarded  as  one  of  malaria,  but  in  which  the 
pigmented  bodies  could  not  be  found.  The  man  had  had  chills  on 
and  oiT  for  several  years  ;  of  late,  the  attacks  had  been  more  frequent 
and  recurred  more  regularly.  Quinine  in  medium-sized  doses  had  no 
influence,  but  very  large  doses  appeared  to  control  the  paroxysms. 
Their  recurrence  excited  suspicions,  and  the  discovery  of  pus  in  the 
urine,  with  decided  pain  on  deep  pressure  in  the  lumbar  region,  in- 
dicated a  more  probable  cause  for  the  irregular  chills. 

Nature  of  the  Organisms. — It  is  very  evident  that  we  are  dealing 
here  with  structures  unlike  any  others  which  have  been  described  in 
human  blood,  and  with  bodies  which  have  no  relation  whatever  to 
the  spirilla,  micrococci,  and  bacteria  of  certain  acute  diseases.  I  would 
call  attention  to  the  remarkable  unanimity  in  the  description  of  these 
parasites  by  Laveran,  Richard,  Marchiafava  and  Colli,  Councilman, 
Golgi,  and  myself.  Laveran's  original  description  is  well-nigh  com- 
plete, and  subsequent  workers  have  done  little  elne  than  confirm  his 
results,  though  to  Marchiafava  and  Colli  is  due  the  credit  of  insisting 
upon  the  amceboid  character  of  the  intra-cellular  form.  Before  dis- 
cussing the  relation  of  the  forms  to  each  other,  it  will  be  necessary  to 
take  a  brief  review  of  cognate  organisms  occurring  in  the  blood,  upon 
which  recent  investigations  throw  an  important  light. 

It  has  been  known  for  some  years  that  hrematozoa  exist  in  the  frog; 
one  form,  a  flagellate  organism,  the  Trypanosoma  sanguinis,  de- 
scribed by  Gruby  in  1843,  is  a  well  recognised  monad  ;  a  second,  the 
Drepanidium  ranarum,  of  Lankester,  is  evidently  a  gregarine,  pos- 
sibly a  larval  form,  as  he  suggests. "  Having  been  long  farniliar  with 
these  bodies,  1°  which  were  very  abundant  during  several  winters  in 
the  frogs  in  my  laboratory  at  Montreal,  I  was  at  once  struck  with  an 
apparent  similarity  to  them  of  the  forms  found  in  ma.'arial  blood. 
The  cresoent-shap-  .  '  ady  in  particular  resembles  strongly  certain  of 
the  gregar         and  I  thought  it  possible  that  we  had  here'  an  instance 


9  Qu(vrUrly  Journal  of  Uicroscopioal  Science,  vol.  xxii, 
w  Canadian  Naturalist.    1883. 


Il 


J.i, 
J 


li 


"^"'^'=^  VI  cttBtjB  may  oe  treated  without 


1 

'      1 .  k 
■      i.ii 

;          :       ^ 

i". 

';   } 

« 

•    I             i 

•■     f.. 


RiyoCZZ^TA!'^'^^^"'  ?'  °°'  "','?««  of  't"  development  as 
fh,;,.  „  ^u  *^  *  *^®  '^*«"'-  I  ""on  tliscovered.  however  that 
there  wore  other  observat  ons  ou  hfl^matoza  which  bJre  r.rdirecUv 

Mit  o;h:Sw".'in";88Tlr'  n'!"^'  ^-  '""'^  ''k^'y  "xJlamS 
mitropnanow     in  ]88J,  announced  the  discovery,  in  the  blood  of  M.o 

?usi^f»°^°^'''' •""''•"'*'i'  °J  ''^'•««'t«''  belo„gin/to  the  iS  a?e  in 
to  not«  fttT'^''"""  "^  '^'''  ^'^"'"'  '"""l  "»'  ^l^tain  ua,    urffi  than 
to  note  that  thev  were  polymorphic,  and  one  sUge  wia  represon  ed 
by  an  aniujboid  body  without  llagolla  representea 

ftver  very  mmilar  to  recurrent  fever  of  man     Steel  fni,n,l  h?o  ^  ^ 

or.Sm"J  fh'  r,T'  ''".I"?""'  "-l  "P«i;«  A'  ld«tSv  of  th 
organwm  with  that  found  inthesttn-a  disease.     Crooksha.t  in  f^- 

h?„nfnFrfT°""°l'- ^''' 7'"    ^''°'^  fl«g«"ate  organism    of  fS 

xn  the  plasma  as  a  pigmented  flagellate  ori?anism      I.   <ri»fl,  ^PP^a" 
Santf  ■.  !\f  ";««'«''  ^^°  identitSTtle  laTh™  nic  b^^^ 

With  this  information,  we  are  in  g  better  position  to  discuss  the 

«i  BMogit^es  Ctvtrnlhlntt,  Bd.  iif,  p  35 

1  <  i"''^1"^°fj'^  lioynl  Micrnscopicat  Society.     1886 

_  tentralblaU  f.  du  MediomUchen  WUsmacliaJh,.,  Nos.  41  ami  42 


1886. 


cl  42.     1886. 


13 

relation  of  the  forms  described  to  each  other,  and  the  zoological  posi- 
tion of  the  organism.  It  in  evidently  closely  allied  to  the  hniiuatozoa 
just  spoken  ot,  and  tlio  facts  which  wo  know  of  thnir  lifo-histo-.y  en- 
able us  to  assort,  with  eroater  couf'uluncu,  that  wo  aro  here  dualing  with 
the  varieties  of  a  highly  rHilymorphiu  H])ocios,  and  not  witli  two  or 
throe  dilferunt  organisms.  The  IligdUto  form  is  donbtloss  thu  adult 
condition  ;  and  it  is  interesting  to  note,  in  contrast  to  the  hivniatiuoa 
of  the  rat  and  of  the  anrra  disease,  the  ('ompiirativo  infrcipicni'y  of  its 
oocurruiice.  I,;ivcrau  nu"  with  it  iiinoty-two  times  in  four  hundred 
antl  thirty-two  casus,  and  Councilman  clovon  times  in  eighty  cases. 
The  stops  in  devulojiment  remain  to  be  worked  nut.  It  seems  clear, 
however,  that  the  pigmented  anid'boid  form  may  become  transformed 
into  a  sporocyst  (rcprcsuutcd  by  Mio  rosutto  form  and  its  changes),  or 
into  an  encysted  body  (resting  form),  tho  cruscent.  Tlie  gaps  in  our 
knowledge  relate  specially  to  llio  form  and  manner  of  entrance  of  the 
parasite  into  the  red  corpuscle.  Uo  tho  solid  iiarticlcs  contained  in 
the  vacuoles  (Kigs.  6  and  G)  represent  tho  earliest  stage  ?  I  tliink  it 
highly  probable  that  they  do,  and  that  they,  with  the  hyaline  unpig- 
montod  bodies,  aro  tho  immature  foims.  Tho  spore-like  structures 
which  result  from  the  segmentation  of  the  rosette  form  do  not  re- 
semble the  small  solid  bodies  seen  in  the  red  corimscles,  but  are  rather 
like  tho  tiny  free  pigmented  forms  which,  in  some  cases,  were  abund- 
ant in  tho  plasma.  Of  tho  latter,  various  sizes  aro  found,  and  it  is 
possible  that  from  them  the  adult  llagellato  bodies  arise.  Golgi  sug- 
gests  that  tho  spores,  resulting  from  tho  segmentation,  pass  to  tho 
spleen,  and  there  attack  tho  red  corpuscles,  in  which  they  (levelop  into 
the  aniicboid  forms.  As  at  present  the  data  aro  not  available  for  a 
final  decision,  a  further  consideration  of  these  points  need  not  detain 
us.  There  is  sufficient  evidence  to  show  that  the  various  forms  aro 
only  phases  in  tho  life-history  of  one  of  the  llagellato  protozoa,  belong- 
ing to  the  order  FlagoUata-l'antostomata.  Mitrophanow  suggests  a 
new  genus,  Hematomonas,  to  include  tho  monad  hiomatozoa  ;  but 
Crookshank,  who  has  carefully  worked  out  the  affinities  of  the  para- 
sites of  the  rat,  tho  fish,  and  tho  surra  disease,  has  referred  them  to 
the  genus  Trichomonas.  The  organism  hero  described  has  not,  how- 
ever, tho  characteristic  marks  of  a  Trichomonas  ;  for  it  lacks  the  un- 
dulating fringe  on  one  side  and  the  caudal  filament.  Nor  does  it 
agree  with  the  features  of  a  Cercomonas  ;  so  that,  meanwhile,  until 
the  true  affinities  are  determined  by  an  expert,  its  proper  place  seems 
to  bo  tho  genus  Ila-matomonas  of  Mitrophanow,  which  conveniently 
includes  all  monads  parasitic  in  the  blood.  Thus  :  genus,  Hsumato- 
monas  ;  species,  Hoematomonas  malariio.  Definition  :  Body  plastic, 
ovoid,  or  globose,  no  differentiation  of  protoplasm,  which  contains 
pigment  grains  ;  flagella  variable,  from  one  to  four.  Highly  poly- 
moqdiic,  occurring  in  (1)  amcoboid  form;  (2)  crescents,  encysted  form ; 
(3)  sporocysts  ;  (4)  circular,  free,  pigmented  bodies.  Tho  name  do- 
signates  the  natural  affinities  of  the  parasite,  its  habitat,  and  the 
conditions  under  which  it  occurs,  on  which  grounds  it  seems  prefer 
able  to  that  of  Plasmodium  malaria,  suggested  by  Marchiafava  am 


Colli. 


and 


Relation  of  the  Parasites  to  the  Disease. — The  same  difficulty  meets 
us  hero  as  in  so  many  affections  in  which  micro-organisms  have  been 
found  :  Are  they  pathogenic,  or  are  they  merely  associated  with  the 
disease,  which  in  some  way  furnishes  conditions  favourable  to  their 
growth  ?  As  evidence  of  their  pathogenic  nature  may  be  urged,  with 
Laveran,  the  constancy  of  their  presence,  their  absence  in  other  indi- 
viduals in  malarial  regions,  tho  destructive  influence  upon  the  blood- 
corpuscles,  and  their  abundance  in  the  graver  forms  of  the  disease. 
But  even  these  considerations,  weighty  as  they  may  appear,  will  not 
carry  conviction  to  all,  in  the  absence  of  experimental  demonstration 
such  as  can  bo  afforded  in  the  case  of  certain  pathogenic  schizomycetes. 


if 


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) 
i 
I 
I 

c 


il 


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l^;•"f:! 


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. ...^  „,  „a«8  „„j,  ^  ^^^^  <^iaKM 


li 


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f 

14 

AttempU  to  iaolato  and  crow  tho.e  hwrnatowa  ouUide  the  body  have 
fulled  Marchiafava  and  Coll.  have  shown  that  tho  inocnlation  of 
healthy  personH  with  blood  taken  from  a  ca^e  of  malaria  in  followed 
in  a  variable  time  by  genuine  a;^uo  paroxysms,  in  which  thi>  blood 
contain*  the  parasiteH  ;  but  in  reKions  where  malaria  in  p.e/ai  .ut  mph 
experiments  are  not  wholly  free  f.om  objections.  /  neru  s  of  n./aiivo 
observations  on  undoubted  cases  of  malaria  would  L  ■  ■onvi.uinjr  1  lav 
no  special  stress  on  tho  three  cases  in  which  I  did  not  find  t)'fl  parasites 
as  the  patients  wsro  not  followed  from  day  to  day  >vith  'lo  aocuracv 
necessary  to  give  any  value  to  the  observatiois,  'it  must  bo  borne  in 
mind  that  ha-matozoa  are  not  uncommon  ;„  laimals,  and,  as  in  the 
rat,  do  not  appear  to  interfere  seriously  u  u-  .ao  health  of  their  hosts 
Under  these  circumstances  tho  association  of  a  specific  form  with  a 
Uehnite  disease  in  an  animal  makes  it  all  tho  more  probable  that  the 
species  18  pathoKenic.  A  furthei-  study  of  the  mrra  disease  is  par- 
ticularly  to  be  desired  with  the  new  light  which  Evans  and  Crook- 
shank  have  thrown  upon  it.  The  conditions  under  which  tho  disoajo 
occurs,  combined  with  its  paroxysmal  character,  are  so  similar  to  those 
of  malaria,  that  a  ful  explanation  of  its  pathogeny  would  have  a  very 
direct  bearing  upon  tho  p:esent  question. 

To  my  mind,  two  facts  in  connection  with  these  hrematozoa  point 
signihcantly  to  their  etiological  association  with  malaria,  ij'irst  tlio 
positive  anatomical  changes  which  can  be  directly  traced  to  their 
action,  changes  upon  which  one  at  least  of  the  most  marked  symptoms 
of  the  disease  depends  ;  I  refer  to  tho  destruction  of  tho  rod  blood- 
corpuscles,  which  can  bo  followed  in  all  its  stages,  and  is  as  well- 
defined  an  alteration  of  tissue  brought  about  by  a  parasite,  as  any  of 
which  we  know.  The  second  fact  is  the  action  of  quinine  upon  the 
parasites.  1  ho  simultaneous  disappearance  of  tho  symptoms  of  the 
disease  and  tho  hiuraatozoa  suggest  that  the  specific  influence  of  tho 
medicine  IS  upon  the  parasites,  though  it  may  be  urged  that  the  nui. 
nine,  wlnlo  curing  the  disease,  simply  removes  tho  conditions  which 
permit  of  their  growth  in  the  blood. 

Fraclical  Cuimdcmtiuns.— Aa  interesting  practical  point  is  the 
diagnostic  value  of  the  presence  of  these  bodies.     There  wore  six  or 
eiglit  cases  in  which  tho  examination  of  tho  blood  proved  of  creat 
service  in  determining  the  existence   of  malaria.     Some  of  these  are 
worth  mentioning.     One  of  the  first  was  a  man  aged  37,  who  had  been 
under  observation  on   three  or  four  occasions  with  anicmia  and  an 
enlarged  spleen.     He  had  had  three  atUcks  of  h<vmatemesis.     There 
was  no  history  of  nrlari«,   and,  from  the  gravity  of  the  case,  I  was 
ed  to  regard  it  a     ■•»  o'  govei  .  splenic  ani  mia.     On  his  fourth  visit, 
however,  a  careful  exa..^inaM,.-^  of  the  bJc.d  r.realed  the  presence  of 
the  parasites,  an;    .    -a.  .,  ,.       (sequence, ,,  .a^re  favourable  prognosis 
in  the  case,  wh.  w    h,.    ^m^,  been  justified.     In  an  instance  of  per- 
mcious  malaria  admitted  to  the  Philadelphia  Hospital,  under  the  care 
of  my  coLcague,  Dr.  J    H.  Musser,  the  diagnosis  rested  on  the  dis- 
covery in  the  blood  of  the  characteristic  changes  in  the  corpuscles.  To 
a  third  case.  No.  41    I  have  already  referred,  and  there  were  four  or 
tive  other  instances  of  chronic  malaria  in  which  the  nature  of  the  dis- 
ease was  determined  by  an  examination  of  the  blood.     On  the  other 
hand,  in  many  cases  of  suspected  malaria,  the  absence  of  these  bodica 
led  to  a  more  careful  examination,  and  to  the  discovery  of  the  cause  of 
the  chills  and  fever.     Four  of  these  were  cases  of  phthisis  with  ill-do- 
fined  physical  signs  ;  in  a  fifth,  after  several  negative  blood-examina- 
tions,  the  ague-like  paroxysms  were  found  to  be  due  to  a  septic  pneu- 
monia ;  m  a  sixth  and  seventh,  renal  disease  was  discovered      I  feel 
confadent  that,  m  malarial  regions,  the  examination  of  the  blood  will 
prove,  in  skilled  hands,  a  most  valuable  aid  in  the  diagnosis  of  mauv 
obscure  cases.  °  ^ 

Melaruemia.— These  researches  on  malaria  throw  light  on  the  forma- 


i . 


lit  on  the  forma- 


IS 

tlon  of  pigment  in  the  blood  and  vnrions  OTfimn  in  the  chronic  cases 
Kvidently  tho  prinmrv  chaiif{«  in  in  the  nil  lilood.rorj)!!^,  Ic,   which  ia 
Rnidually  .lc!,troyc(l  by   tho  iimd'hoid  form  of  tho  \<>  »sitp      Kvory 
Hliif{o  of  tldH  procem,  cnn  lit)  rendily  tracod,  and  thoHO  (.'licrvafioiiH  boar 

?'"ir  m\"^°  •'""*'""'  ^'''"''*  ""  "'"  ""«'"  °^  *•'«  I>i(^iiient  in  the  blond 
tHulf.  Tho  i)iKni(«ntary  doKencmtion  of  tho  rod  rori>unfles  nnfired 
loiiK  a^o  by  brorichs  and  by  KoIhcIi,'"  wnn  no  doubt  th»  hbiiio  an  hero 
doHonbol.  Tho  gradual  accumulation  of  tho  gr^uuleH  in  tho  si.leen, 
hvor,  and  bone-marrow  leads  to  tho  characteristic  nidanoms  of  thono 
organs.  I  sought  carefully  for  evidence  of  active  interference  with 
these  parasites  on  tho  part  of  the  white  blood-corpuscloH,  but  on  only 


Fig.  14,— A  cnlonrlcM  corpuscle  Btiidled  for  an  hour  aihI  «     air  ,i„,i.,™    ..,  i. 

two  or  three  occasions  was  this  seen.  Once  a  crescent  as  found  inside 
a  colourless  corpuscle  (Fig  13).  and  again,  as  sho«  at  Fig  "4! 
corimscle  gradually  enclosed  two  free  pigmonte.l  bodies  The  Kreaier 
portion  ot  the  pigment  resulting  froa,  the  destruction  ol  :he  nonaK 
piokodoutby  thecellsofthesnloouand  bone-marrow,  ,  hie  also  no 
Joubt,  as  in  health,  remove  tiie  elieto  rod  colls  and  tl.  .r  omua'nts 
inownTH^'^T'  '"'^T''  """"K**  ^hon  Stewardson'^  wrote  s  welt 
known  article  has  now  become  very  rare  in  I'hUadelphi,.  In  theso 
cases.  Marchia  ava  and  Colli  have  found  tho  capillaries  0.  tho  vaous 
organs  hllod  with  corpuscles  contaiuing  pigment-grains  ^^  uch  appear 
enclosed  in  a  hyaline  matrix.  Councilumu Ind  Ab1,ot'^  h«  '  descE 
the  same  change  and  I  am  indebted  to  Dr.  Councilman  L  the  speS 
men  from  which  the  accompanying  sketch  was  taken  (1  -  15)  If 
represents  a  small  brain-capillary  filled  with  corpuscles,  .  '  many  of 
which  are  pigmented  bodies  which  stein  deeply,  and,  so  fa    aTcan  be 


Fig.  15.— Sketch  of  a  cipillftry  vessel  of  grey  matter  of  brain.  Case  of  per- 
nicious comatose  malaria— Dr.  Councilman.  The  red  corpuacles  art  seen 
In  outline,  and  in  five  there  are  pigmented  bodies. 

ascertained,  are  identical  with  the  pigmented  organisms  met  w  th  in 
the  red  corpuscles  during  life.  Only  one  instance  of  fatal  m.i  laria 
came  under  observation,  a  man  aged  70,  admitted  to  Dr.  Mu  "ier'a 
wards  on  October  25th.  He  had  been  on  the  Isthmus  of  Panam;>  and 
in  Georgia,  and  had  chills  and  fever  in  both  places ;  last  chili  was 
three  days  before  admission.  He  had  also  had  haematuria.  He  was 
very  anfemic,  the  spleen  was  slightly  enlarged,  the  temperature,  101.  .3°. 
There  wa«  great  stupor,  and  he  was  roused  with  diflBculty  ;  the  tongue 
was  dry.  The  temperature  became  subnormal  on  October  27th  and  28th. 

18  Areliiv.  d.  I'hysiologie,  1875. 

1'  Amtnican  Journal  0/  Mtdical  Sciences,  1851. 

'^0  American  Journal  0/ Medical  Sciences,  1886. 


^: 


f 


>» 


i . 


;i 


H 


ji 


^ 


^',; '■■■." n,m,m„  Of  ™k,  m»j,  be  treated  without 


I 


«*»" 

'n 


i6 

Examination  of  the  blood  showed  many  pigmented  bodies  in  the  red 
corpuscles,  numerous  free  circular  forms,  a  few  crescents,  and  several 
flagellate  organisms.  The  stupor  deepened  to  coma,  and  he  died  on  the 
night  of  October  28tb.  The  spleen  and  liver  showed  typical  pigmenta- 
tion, and  the  bone-marrow  was  also  very  dark.  The  spleen-pulp  con- 
tained free  pigment  and  many  large  cells,  some  of  which  were  filled 
with  dark  granules,  while  in  others  there  were  bodies  identical  with 
the  small  pigmented  forms  so  abundant  in  the  blood  during  life.  The 
marrow  jiresonted  similar  changes.  The  number  of  red  corpuscles  con- 
taining the  pigmented  bodies  was  not  great,  nor  wore  the  capillaries  of 
the  liytr  or  the  brain  stuffed  with  them,  as  in  the  instances  of  pernicious 
malaria  just  referred  to.  Probably  this  was  an  instance  of  severe 
malarial  cachexia  of  many  months'  duration,  and  scarcely  should  be 
grouped  with  the  pernicious  comatose  form. 

To  my  colleagues,  Drs.  Curtin,  Neff,  and  Musser,  I  am  indebted 
tor  the  privilege  of  examining  the  malaria-cases  in  their  wards;  and  to 
my  resident  physicians,  Drs.  Donohue,  Albertson,  and  Westcott,  for 

sistanco  which  materially  lightened  my  work. 


London  :  Primed  by  the  British  Medical  Association,  i6ia,  Strand,  Vf.C~ 


"-.'«v«r\,«j»;-:(-.^:»VTi:T,r,.;;-----;-- 


'CXYVII 


\,  Strand,  W.C, 


tofir 


1<\=,'  I 


ANTIFEBF 


A  FEW  months  ago  Drs.  Cahn  and  Hepp 
announced  from  Kussmaul's  clinic  the  dis- 
covery of  a  new  antipyretic,  which  they  named 
antifebrin.  A  full  account  of  their  observations 
has  more  recently  appeared  in  the  Berliner 
Klinische  Wochenschrift,  Nos.  r  and  2,  1887. 

The  drug  is  known  chemically  as  phenyl- 
acetamide  or  acetanilide  (QH.C.H^OHN), 
and  is  formed  by  the  action  of  heat  upon 
aniline  acetate.  It  is  a  neutral  body,  and  in 
this  respect  it  differs  from  all  other  anti- 
pyretics, which  are  either  phenols,  like  sali- 
cylic acid  and  resorcin,  or  bases  of  the  chino- 
line  series,  as  thallin,  antipyrin,  and  quinine. 
It  is  a  white  crystalline  powder,  insoluble  in 
cold  water,  but  reaaily  dissolvmg  in  hot  water 
or  alcoholic  solutions.  The  taste  is  not  un- 
pleasant. The  dose  is  from  8  to  12  grains.  In 
larger  amounts  it  is  not  poi.sonous,  though  it  is 
advisable  not  to  exceed  30  grains  in  the  day. 
Usually  8  grains  will  be  found  an  effective 
dose.     It  is  conveniently  given  in  spirit  and 

-       ■  1:1.  .    r...   .1.;,  J . 

of-OT  'iHT?  I  ol'9or  5^A\  3.TniT?jodui9i  oq;  '-wv 
01  ;b  'pez  am  UQ  -SBpdis^ja  q]iA\  pajtoenB 
«BA\  aq  qjoz  aqj  uq  •?!  XannuEf  icjidsoH  Biqd 
i^P^IRd  "!  asBasip  pioisniu  joj  psuiqdaj^sHM 
'1?  paSB'^H  •J--(-An.iBqD)  TIIAX  asv3 

•sanoq  aajq;  oj  omi  uiojj  ui  ^L  o-\  ^t' 
luojj  ajniBaadiuai  aq?  paonpa.!  sA^p   aAissao 


10a' 


= 


99° 

I.  Rei 

most  md      Case  IV.  (Char 
ning  usii  admitted  Novemb-- 
ministral  the  4th  the  temper, 
in  threq  date  until  the  13th- 
sions  a  |  At  8   p.m.  on  the 
temper 
in   si.xt 
occasio 
time  Wc 
was   6| 
the   foi 
Case  X 
XVIII 
XX.,  7f 
ten  houj 
In  sel 
was  una! 
and  XII 
peritoni 
sipelas. 
j       Thee  -     _ 

ncnallu.  J_ 

j  9J3q:i  puB'ponS  scm  uoiiipi-. 
I  'ssauiiijqo  jqSijs   jo   paujB' 
!  aAjaMj  puB  uaAaja  naa.AAiagr 
j  Aq    puu  'asu    oj  ueSaq  51  '' 
j  SBM  ajnjBjaduia}  aqj  -wk", 

'    SSnjOjd  q}lA\  'o?  JO|[BJBSE  ' 

ifg     "uaAiS  sBM  'iitA  uS  '" 


■05C 


1  o.)'- 


"  '-^^^-^^^^^^t^^^^f^ 


) 
} 
I 

I 
c 


f 


\\ 


w 


'!l 


^-xy 


VII 


ANTIFEBRIN. 


A  ^^^   """"'h'  ^go  I^'-s-  Cahn  and   Hepp 
r\  announced  from  Kussmaul's  clinic  the  dis 
covery  of  a  new  antipyretic,  which  they  named 
ant.febnn.  A  full  account  of  their  observations 

i^W/ij.  Wochenschrift,  Nos.  r  and  2,  1887 

The  drug  is  known  chemically  as  phenyi- 
acetamide   or  acetanilide    (C„H  C  H  OHN^ 

and  is  formed  by  the  actiL%/hea%on 
amlme  acetate.  It  is  a  neutral  body,  and  in 
this  respect  it  differs  from  all  oth;r  anti- 
pyret.cs  wh.ch  are  either  phenols.  like  sali- 
ylic  acid  and  resorcin,  or  bases  of  the  chino- 

mesenes  as  thallin,  antipyrin,  and  quinine. 
It  IS  a  white  crystalline  powder  insoluble  in 

or  alclor  ^"V^^dily  dissolving  in  hot  water 
0  alcohohc  solutions.  The  taste  is  not  un- 
pleasant. ThedoseisfromSto  12  grains  In 
arger  amounts  it  is  not  poisonous,  though  it  is 

Usually  8  g,,.„,  ^i„  be  found  an  effective 
aose.     It  ,s  conveniently  given  in  spirit  and 

sweetened  water. 

During  the  past  three  months  I  have  used 

LdaTZ   u  ''"f  ^Philadelphia  Hospital 
and  at  the   Hospital   of    the   University  of 

rheZ.   '''=     P'«"nsy,    x;     peritonitis/  x 

ule  s'^'lT'  '  =  '"^^™'"-'  fever,  x.     ks  a 
re,  8  grams  were  given  when  the  temuera- 

«rc  .0.C  above  xo3|^  and  hourly  observa- 
tions were  made  for  six  or  eight  hours      in 
-eralc      3of  phthisis  4  grafns^'eTgiv 
ZnnJr   '"""  '   '^y-     ^^he  maximum 

10    F?  r  "•  "V  ^'"^  ''  ^"'"«  i^-^- 

be  roteH      .     '^'  '^'  ^^''''  °f  the  drug  may 
J^ted  under  the  followin..  h.-,.i. .     ^      ^ 


I.  J^^^uc/ion  of  T,mperature.~Th\5  jg  the 

most  marked  and  characteristic  action,  begm- 

,   nmg  usually  within  an  hour.     In  eighteen  ad- 

I  '"'"f'-anons  the  fall  was  over  2°  in  this  time- 
!   >n  three  instances  a  fall  of  3°,  on  two  occa' 
I  sions  a  fall  of  4°.     In  thirteen  instates  the 
i  temperature  was  reduced  4°  in  two   hours 
•n   sixteen   adm!  .istrations   3°,  and  on  fou; 

occasions    S   .       The    frrpatpcf-   Hr -^u-        ,  . 

Hm^  •    V.  greatest  drop  within  th  s 

time  was  in  Case  XXIV.,  in  which  the  fall 

tT?  r  ,1  ■    •  '^^^   ^'^^^^^^   reduction   was   in 
tne   tollowinc  •    Case    T      so    ;,,   c        1 
rase   Y     r■^o■      r  '  "    ^^^    ^OUrs  ; 

vvtt;  '  i  ■'"  '"'"""^  ^  half  hours;  Case 
X\  III  71  ,„  two  and  a  half  hours  ;  Case 
^^A-,  7  in  seven  hours  ;  Case  XIX.,  73°  ,„ 
ten  hours.  '^ 

In  seven  administrations  the  temperature 
was  unaffected  by  the  eight  grains.   Cases  VII 
and  XIII.,  both  of  pneumonia  ;  Case  XXIII  ' 
peritonitis;  and  Cases  IX.  and  XVIII    erv' 
sipelas.  ■'    ^' 

The  duration  of  the  reduction  was  variable 
usually  from  three  to  six  hours.     The  follow- 
ing cases  illustrate  well  the  antipyretic  action     ' 
ot  tnis  drug : 

Case  XI.  (Chart  I.).-Man,  aged  .2   ad 
m.tted  to  the  drunkards'  ward  of  the  Phil^del-' 
Ph.a  Hospital.     A  fewdaysafter  admi.ssion  he 
was  noticed  to  be  a  little  short  of  breath,  and       ' 
on  examination  of  the  lungs,  there  was  dulness'    \  \ 
with  rales  and  feeble  blowing  breathing  at  tS    \\ 
ngh   base.     On  January  3.  at  5  i'.m.,  the  tern     i '' 
perature  was  1051°.     Antifebrin,  gr.  viii  was 
given,  and  the  fever  gradually  fell,  as  the  chart       ' 
shows,  until  midnight,  reaching  100-      By  x 
A.M.ithadrisentoxoxr.     At  7  p.m.' on  (he 
5th  the  temperature  was  nearly  xo4°  and  an 

good  etr'  ^'^  ^"'^'^"  "^^  ^'-"  -'h 


^1 


.'V  IN  1 1  r  r^  D  i\  1  i\ . 


^^-^ 


January  j. 


Jan.  6. 


Pneumonia 


^       Cask  IV  (Chart  II.).— Rachel  C,  aged  21,  1  was  no  collapse.     The  thermometer  did  not 

I  ^'^"""^'^  November  3  with  typhoid  fever.   On  ;  again  reg.  .er  above  103!°  '"  her  case. 

'"(  the  4th  the  temperature  was  104°,  but  from  this  |       Case  X.  (Chart  III.).— J.  B.,  aged  35,  with 

date  until  the  13th  it  did  not  rise  above  103°.  |  chronic  phthisis  and  high  fever.     The  chart 

At  8  P.M.  on  the  13th  the  temperature  was  '  shows  h(nv  r::pidly  the  antifebrin  in  three  sue- 


II 


i^     ^ 


Cask  IV. 

November  13.  November  tl     N.-v.  ij. 


a      't        vo    CO  o\ 


e-        0.     St 


N     in        CO    fo        ro     -> 


!     .^ 

> 

1 

1 

i         i 

.„s° 

^    1     1 

1 

! 

i 

r — 

/ 

1.1  jO     - 

/ 

102"  - 

»t 1 

\ 

/ 

\ 

A 

1 

1111°  . 

/"^ 

r       V 

r 

\ 

100°  H 

/ 

\ 

/\ 

/ 

V 

r,n°    ■■ 

i 

\  1 

/ 

V 

,,8°   - 
97"    - 

i                    : 

,., 

1 

1 

^ 

i 



-— L 

■     ! 

Typhoid  fever. 


;04-^".  Antifebrir,  gr.  viii,  was  given.  By 
I  ten  o'clock  there  was  a  fall  of  5°,  with  profuse 

sweating.  At  ii  p.m.  the  temperature  was 
1 97°-     At  12   A.M.  it  began  to    rise,  ■and    by 

2  A.M.  was  99.4°.  Between  eleven  and  twelve 
I  o'clock  she  compiained  of  slight  chilliness, 

but  the  general- condition  was  good,  and  there 


cessive   days  reduced  the  temperature  from 
4°  to  7°  in  from  two  to  three  hours. 

Case  XVIII.  (Chart  IV.).— F.  H.,  aged  31, 
was  trephined  for  mastoid  disease  in  Philadel 
phia  Hospital  January  15.    On  the  20th  he  was 
attacked  with  erysipelas.     On  the  23d,  at  10  j 
A.M.,  the  temperature  was  io6|°  ;  at  1 1, 1051". 


Jaiiiuiry  j. 


Pneumonia. 

t  II.).— Rachel  C,  aged  21,  j  was  no  collapse.     The  thermometer  did  noi 

er  3  with  typhoid  fever.   On  ;  again  register  above  103^°  in  her  case, 

iture  was  104°,  but  from  this  I       Cask  X.  (Chart  III.).— J.  B.,  aged  35,  with 

;  it  did  not  rise  above  103°.  |  chronic  phthisis  and  high  fever.     The  chart 

13th  the  temperature  was  '  shows  Iiow  mpidly  the  antifebrin  in  three  suc- 

Cask  IV. 

November  13.  NovemU-r  i -,.     X'v.  13. 


*    •*. 


'■  '^    »•'■    '■o    !:'•    <  <    <  ■-    -it, 

n     f        >o    00  c>    -•  -      -  n     in        M    to         rn     'r 


II      !       ! 

!        1        j 

1 

r 

aJ 

/ 

, 

A 

1 

/^ 

'      V 

\ 

/ 1 

\  t- 

/j 

\ 

A 

/ 

y 

v_ 

/ 

v 

: 

.  - 

,.     1 

jWi           J            1 

-   .   .       .  i 

Typhoid  fever. 


IOmeter  did  not 
her  case. 
B.,  aged  35,  with 
ver.     The  chart 
rin  in  three  suc- 


''^^t7^/fy?\t^i. 


—      \OaiTJi\ 


'^e  g^rs 


\^nh 


WA(/iy\ 


He  was  g.ven  ant.pyrin,  gr.  xv,  and  quinine, 
gr.  XX.  At  3  P.M.  the  temperature  was  still 
above   103",  and  a  second  dose  of  antipyrin 

S,^'7;     ^^5^.M.,quinine,gr.xx.'He 
had  had  also  qu>n,ne.  gr.  v,  every  four  hours. 
At  8  P.M.  the  temperature  had  fallen  to  iool° 
at  II  P.M.  to  99°,  and  at  3  a.m.  to  98°.     0„' 

vrintd      '""  ""  ^^^'"  '^°5°.  and  anti- 
pyrm  and  qumme  were  given,  with  a  reduc- 

fon  of  4;  in  five  hours.     On  the  .5th  anti- 

anTeffec?  'i ,""  ""'  ^"'"  ^^'^^"'  ^^^out 
cal  t^rl'  f  T  '^^"^^^^'•'■^'^J  to  the  medi- 
cal ward,  and    the   antifebrin   was   used   as 

hwn  by  the  chart.     The  last  dose  caused  a 

all  of  7f  °  m  two  and  a  half  hour=      The  oa 

-ent  subsequently  did  well.     The  chart  is  of 

merest,  as  it  affords  a  comparison  between 

the^act.on  of  antipyrin  with  quinine,  and  that 


!  This  pa( 
fever  dj 
;  dayfronj 
'  a  second 
;  the  first 
i  XI.  and 
In    ty 
:  prompt 
j  young  n 
I  temperai 
i  the   dru, 
''  and  afte 

!  3°  to  5°, 

I  more  sti 

In  th) 

each  ins 

In  ph 

usually  I 


^y?^'f 


-^m 


"frfl 


vr/r, 


without 


) 
i 
I 

I 

c 


I     j 


tm 


I  i 


if 


m 


{',\'  ■> 


Cask  XXIV.  j 


He  was  given  antipyrin,  gr.  xv,  and  quinine, 
gr.  XX.     At  3  P.M.  the  temperature  was  still 
above   103°,  and  a  second  dose  of  antipyrin 
was  given.     At  5   ,...m.,  quinine,  gr.  xx.     He 
had  had  also  quinine,  gr.  v,  every  four  hours 
At  8  P.M.  the  temperature  had  fallen  to  iool° 
at  II  P.M.  to  99^,  and  at  3  a.m.  to  98°.     On 
the  24th  the  fever  was  again  105°,  and  anti- 
pynn  and  quinine  were  given,  with  a  reduc- 
tion of  4°  in  five  hours.     On  the  2Sth  anti- 
ipyrm  and  quinine  were  twice  given,  without 
any  effect.     He  was  transferred  to  the  medi- 
cal ward,  and   the   antifebrin   was   used   as 
shown  by  the  chart.     The  last  dose  caused  a 
tall  of  7f    ,n  two  and  a  half  hours      The  pa 
tient  subsequently  did  well.     The  chart  is  of 
interest,  as  it  affords  a  comparison  between 
the  action  of  antipyrin  with  quinine,  and  that  i 
lof  antifebrin.  | 

In  several  cases  the  dose  of  gr.  viii  did  not 

jseem  sufficient.  In  seven  administrations  little 

or  no  effect  followed.     This  was  particularly 

noticeable  in  the  pneumonia  cases.     In  Case 

AUi.,  with  almost  complete  involvement  of 

[the  right  lung  and  affection  of  the  left  base 

aL^n'^f '''"''  ^'°"^  '^^  5th  to  the  loth 
ranged  from  102°  to  105°.  Antifebrin  was 
o'ven  Six  tunes,  thrice  without  effect,  and  on 
three  occasions  it  only  reduced  the  fever  a 
aegree  or  a  degree  and  a  hair  Thallin  gr 
•V,  twice  brought  the  temperature  down  3° 
Y»a  4  ;  but  the  most  effective  agent  in  this 
■^e  seemed  to  be  the  cold  pack,  which  re- 
"Ced  the  temperature  from  105°  to  98^°. 


I  1  his  patient  had  delayed  resolution,  and  the 
fever  did   not  subside  until  the  thirty-ninth 

,  day  from  the  initial  chill.    In  other  instances 

!  a  second  dose  repeated  an  hour  or  more  after 
the  first  produced  the  full  effect,  as  in  Cases 

I  XI.  and  XVIII. 

,  In  typhoid  fever  the  action  was  usually 
prompt  and  satisfactory.  In  Case  II  a 
young  man,  aged  25,  with  persistently  high 
temperature  and  marked  nervous  symptoms 
the  drug  was  given  on  fourteen  occasions' 
and  after  each  dose  there  was  a  drop  of  from 
3°  to  5°.  In  the  milder  cases  the  effect  was 
more  striking,  as  in  Case  IV. 

In  the  erysipelas  cases  the  action  was  in 
each  instance  most  decided. 

In  phthisis,  with  high  fever,  the  drug  was 
usually  given  in  a  single  powder  of  gr.  viii 
when  the  temperature  was  above  103°,  but  in 
three   cases   the    plan    was  tried    of 'giving 
gr.  IV  four  or  five  times  a  day.      This  did 
not  seem  very  successful,  and  the  patients  did 
not  feel  so  comfortable  as  with  tho  single  dose. 
In  a  remarkable  case  of  quartan  ague  anti- 
febrin in  8-grain  doses  given  before  or  during 
the  paroxysm  seemed  to  be  without  effect    ; , 
One  curious  circumstanne,  \...,.,evpr  i-  «---.'      ' 
mentioning.     The   lad   had  always  with  the 
fever  the  most  intense  general  urticaria,  which 
the  antifebrin  seemed  to  prevent,  much  to  the 
patient's  comfort. 

2.  Action  on  the  Circulatory  Sy stem. -AJ^x^^Wy 
with  the  reduction  of  the  fever  the  pulse  would 
^^"'  ^"d  a  drop  of  20  or  30  beats  in  two  or 


\i 


ft  tfH  %  %,« 


January,  1887. 


tlirec  hours 


was  lrt(]Ufntiy  noted.      Th 


Case  II.,  with  a  pulse  rate  of 


us,  111      the  severe 


and  the 


1 1} 


tempt 


perature  at  105^  the  pulse  fell  to 
«4  m  four  hours.  In  another  case  the  pulse 
fell  from  jjo  to  90  in  four  hours.  A  marked 
increase  in  the  pulse-tension  was  observed  in 
several  cases.  Kven  with  a  rapid  fall  of  from 
5  to  7»  in  two  or  three  hours,  there  was  no 
evidence  of  heart-weakness.  Slight  cyanosis, 
which  IS  mentioned  by  one  or  two  Cerman 
writers,  did  not  occur  in  any  instance. 

3-  '^«''^fl/%— Aswiththallinandantipyrin 
the  action  of  antifcbrin  is  almost  invariably 
accompanied  with  profuse  perspiration,  whirl, 
IS  often  the  first  effect  of  the  drug.     Repeat- 
edly I  have  seen  the  forehead  beaded  with 
sweat  half  an  hour  after  the  administration 
o    8  grains.     This  is  sometimes  a  most  un- 
pleasant  feature  in  the  employment  of  the 
drug,  and  is  the  only  one  of  which  the  patients 
have  complained.      In  several  instances  the 
'Irug  was  combined  with  atropine,  but  without 
much  effect.    It  does  not  seem  to  increase  the  ! 
night-sweats   in    cases  of    phthisis;    indeed    ■ 
under  its  use,  one  patient,  who  sweated  much  ' 
with  the  afternoon  dose,  had   drier  and    in 
consequence,  more  comfortable   nights.  '  In  i 


per  minute,      stopped  iti 


weaken  the 

I  4-  On  ih 
was  a  marl 
of  the  cas« 

,   of  the  inci 
5-  The 

,   seemed    ui 
often  folic 
istration. 
themselvei 
this  mattei 
There  w 
which  we  s 
pyrin  and 
vomiting ; 

there  was 

IS  so  comi 

These 

of  Cahn 

that  we  hi 

erful  anti 

from  unp 

tage  also 

I  have  u 

wholesale 


I     ' 


u. 


) 

i. 

1 

) 

1, 

\ 

t'       ' 

1 

1 

\ 

\ 

\ 
1' 

\\ 

%\ 


^^'--MM-;-;:;,-^-— ::^^,..no.„„... 


hn 


'\ 


WH 


.nT.^    :  ^  P"lse.rateof  ,,2  per  minute 

and  the  temperature  at  .05°.  the  pulse  fell  to 
84  m  four  hours.  In  ar^other  case  the  pulse 
fell  from  X30  to  90  in  four  hours.  A  marked 
.ncrease  m  the  pulse-tension  was  observed  n 
several  cases.  Even  with  a  rapid  fallTfo^ 
S  to  7  ,n  two  or  three  hours,  there  was  no 
evdence  of  heart-weakness.  Slight  cylnosis 
which  IS  mentioned  by  one  or  twn  r  ' 

writers!  HiH  r.^^  "^°  (merman 

writers,  did  not  occur  in  any  instance 

I     3.  Sweaf/n^.-As  with  thallin  and  antipvrin 
Ithe  action  of  antifcbrin  ,s  almost  invSr; 
laccompanied  with  profuse  perspiration  wh'h 
Is  often  the  first  effect  of  the  drug.     Repeat 
tdly  I  have  seen  the  forehead  beaded  wUh 
Iweat  half  an  hour  ifff-r  ti,^      . 
If  8  ^rain^      Th      •  ^  administration 

easant?.  .         '  "  ^"'"^^'"^es  a  most  un- 
asant   feature  in  the  employment  of  the 
f  rug,  and  is  the  only  one  of  which  the  patients 
ave  complained.     In  several   instance   Thl 

iiucn  eriect.    It  does  not  seem  to  increasn  th« 

Kh  the  afternoon  dose,  had    drier  and    in   1 
onsequcnce,  n,ore  comfortable  ri'^h's'  In  i 


^  weaken  the  paS„r         '™""« '"™'"° 

.v^■ata:tut:^-J,^^r^^"«— ' 

onje  cases.    ThisTp'rl^'   rdirrru 
o(  the  increased  arterial  tension. 

hl^f  1  "  P'"'"-'iiral  patients  e;<pre«ed 

.hi:rt::;.™'^°--'>''''-*-t''herst 

whIrhT  ""'  "°'"  °'  ""=  lisagreeabie  effects 

;r.t:rtr,!rVh:i°''°"'''"^"'-" 
:-it,„,  d,:i.hi^?,:-,r--' 

-cr„r„ff-xr"---- 

of  cS  ""J",^  ■"'servations  confirm  those 

,h=,        .  ""''.  ""PP  ""'I  °'1>"S,  and  I  think 

ful  an,  rn  ■ "  ""'•'''"'"  »  P'O-^P'  and  po„' 

from  ""=''""  =««'.  easy  to  take,  and  free 

.  «aZrr"'  '""'"    "  ""'  "-  advan! 
whoteale    '•       °"'^  ""'■  «"'»  -  <"■"«. 


;i 


I 


mmm 


^XKy/// 


•  f  144  was  not  roducod  .„  I,,,  tlnn  9.       t.  '''  '"''  *''^  Pnlse-rate 

"-  "-'  1"..  This  patient  suf  ^^  ^^  ^^  :!"""^'"'  -O'n,  between 
-soles  especially  in  the  lin.bs  17 1  '""'"' ^"""'- '•^"  ^'- 
— "-'  absent,  but  returned  if  1  ,1  *  f"';  T'^""  ^'"'^  '^-"'- 
P-vf  ".  strength  and  feels  well  w  dl  t ""  'f  ''''  «''^'  ^-s  in. 
iH'en  takino.  one-,,uarter  of  a  .rain  e     .  f         '        '"^'  ''•     •^''^'  '"'■^  '.,>w 

I  .i^ave  spartein  for  periods  ;■'"  ''"'"'•^  ^"'-  ^^'"^  '"""ths. 

f''b-  ...antities  of  oue-lhirdt"  :"  I  ^:;;r'  ''''''  '^  ^  "'-^''s  in 
;lo.se  was  continued  in  one  case  for  n  "  "'l^'''  «''»"^^>  the  latter  large 
!-^i->  with  one-sixteenth  ofT^j  '^^  P'^''  ^^^fit.  U  is  best  ^ 
'"-ease  up  to  two  grains,  if  n^^  arr^i,  h"'  '""^'  '"'^'  ^^-'"^^% 
-•eulat.on   is  obtained.     When   t   e  do  o  ''  ^T""  ''''''  ^^  t^'e 

'•-■It  does  not  seem  so  good  ;  son.e  L^"  ^'7"  '^"^^  ^'-i"«.tly  the 
'-iuced  without  loss  of  em.;.  T^^Jn  7'"  '^'  ""^'  '"  ^'-'"''"v 
J"'  f  ^-  --•^''-  "-  palpitation'",^,  ;:";■■  ''.  — '"ation.  Th^ 
"<  '"^'l'  tension,  and  a  feeling  of  .nv-   \ve  ^'""'  """'''  ^-^l*'^  I'-J'^e 

_  ^••artein  begins  to  act  in  about't  lil  ""''•  '""  '''''  '"'"'^^^-^^l 
^^y  [^;?  '-:"th,  and  its  actio,;tL  tn  Zit  1  '''''  '  '^'^  ^-"  ^^^en 
'•'^!-l.ty  of  action,  at  first  consistin-  ,  7  ,  •'  '"  ''''  '''^"••«-  'i^''- 
-■'--!'  t..nsion  not  occurring  mil  i  •;  H'^""  f  ^^''^  ^«--^' --.f 
^^i;:"-ten.  in  a.s,-stolic  conditions  o  val  u  .  T'' '"'""'^'^^^  ^'^^'  "-  <^^' 
'■ft'et  ,s  desired,  giving  it  superioriv  ot  T''  ''^''''  '^   ^I'^^^dy 

^"  these  conditions,^  too    !    ^^1    d         Tlf^''^^  "^'^'""-  ^'^ugs. 
t-"tl.  to  one-quarter  of  a  t    n)    i;!:  ^''^'f'  '^^  -Ployed  (o^^-six- 
l"7-f;'Hy  to  stinn.Iate  and     g      'te The"     '"\'?"  ^"'"•^-'  -- 
a«er.al  tension,  perhaps  not  nlr    Hn "  ""'^  '^"  ""'^^'^^^  '•-'^  of 

"f  '"creased  cardiac  force.  "  '^''  "«""^^^  accon.panin.ent 

j;;^;'.'...ofthesurf.eel>nh:c;i:::^:;;;^-  ^^ '''-  'r-- 

after  a.lnuinstration  in  „u.st  cases.  ''''"  ^*""  '"  ^^^o  l'o"rs 


THE  CAHDIACRELAXrOX.  OP  CHORE  V 

-— .  cu....  ,„!^:;:^:;;;^;^  Os.K.,  3I.I,, 


) 
I 

c 


i'M 


M 


-if 


,^ 

1 

f ' 

'  i 

p 

■B  l\ 

":'n 

'if    • 

( 

I':  I 


!  i 


372     OSLER,    THE    CARDIAC    RELATIONS    OF    CHOREA. 

a  deatli.  By  far  the  most  serious  fact  in  the  clinical  history  of  the  dis- 
ease is  the  occurrence  of  endocarditis ;  but  here  the  danger  is  renidtc, 
not  immediate,  and  lies  in  the  changes  which  an  acute  valvulitis  may 
initiate. 

A  satisfactory  study  of  the  cardiac  relations  of  chorea  must  embriic(! 
the  condition  during  the  attack,  and  the  subsequent  heart  history  after 
a  period  of  years.  The  first  (juestion  has  engaged  the  attention  of  man  v 
workers,  and  an  attempt  is  here  made  to  work  out  the  second  on  a  scale 
not  hitherto  attempted. 

I.  Condition  of  the  Heart  during  tiii;  Attack. 

Oftentimes  the  extreme  jactitation  renders  the  examination  of  a  clionic 
child  difficult  or  even  impos.?ible.  I  make  it  a  rule  to  examine  the  bare 
chest.  Auscultation  through  the  clothing  is  not  trustworthy,  as  soft 
murmurs,  readily  audible  with  the  stethoscope,  may  easily  escape  detec- 
tion. It  is  a  good  plan  to  let  the  child  lie  quietly  on  a  lounge  for  some 
time,  and  make  the  first  examination  in  the  recumbent  position  when 
the  heart's  action  is  less  rapid.  Subsequently  the  eflfect  of  exercise  and 
of  the  erect  posture  may  be  tested. 

In  chorea,  as  in  rheumatism,  the  evidences  of  cardiac  disease  must  l)e 
sought  for,  as  it  is  rare  to  hear  complaints  of  either  palpitation,  pain,  or 
other  symptoms  which  would  direct  attention  to  the  heart. 

The  cardiac  disturbance  is  indicated  by  the  presence  of  murnuirs, 
alteration  in  the  rate  or  rhythm  of  the  heart's  action,  and  by  pain. 

A  nuirmur  at  one  or  other  of  the  cardiac  areas  is  by  far  the  most 
common  sign  and  is  present  in  a  considerable  number  of  all  cases.  Of 
410  cases  in  the  records  of  the  Infirmary  for  Nervous  Diseases,  tlicre 
were  120  which  presented  a  heart  murmur  at  the  time  of  examination. 
In  at  least  40  cases  there  was  either  no  note  or  an  imperfect  one,  and  in 
very  many  the  exigencies  of  out-patient  work  prevented  a  very  tliorouirli 
examination.  It  can  safely  be  said  that  in  over  one-third  of  the  cases 
a  heart  murmur  Mas  detected,  and  I  have  no  doubt  that  this  number 
would  have  been  much  increased  had  each  child  been  stripped  and 
special  attention  given  to  the  auscultation  of  the  heart. 

Of  the  120  cases,  ll;3  presented  the  apex  systolic  or  mitral  nuirnuu', 
in  7  a  basic,  and  in  '.]  both  apex  and  basic.  In  15  cases  the  heart'H 
action  was  noted  as  rapid,  and  in  6  as  irregular.  Pain  was  not  a  fre- 
quent complaint  and  was  noted  in  only  (5  or  7  cases. 

It  is  commcm  experience  that  the  special  indication  of  heart  trouble' 
in  chorea  is  the  i)resence  of  a  soft  systolic  bruit,  heard  best  at  the  apex 
or  over  the  })ody  of  the  ventricles  and  not  often  propagated  to  or  bevdml 
the  mid-axilla.  Basic  systolic  murnuirs  are  usually  associated  with 
auffimia  or  debility.  Diastolic  and  presystolic  murmurs  rarely,  if  e\ci', 
occur  in  acute  chorea. 


CHOREA. 


had  almost  coaso.l  „,:, !    t  "S;;];!"  V--"-»i-     Tl.^  ,^:^;,:;^ 
40O  post-mortem   records   il i^t re  "l  ?;,:^  'Y^'r^'-  •  '^'''^  *'"'^"l''^v    ^ 
J'.vpertrophy  of  the  heart,   s      ew  at       I  ?     ^V''^"*^^^  «''»^^- '«'"  ■<^1M  t 

nu,rK.v,,,sirreguh,rwartv   -e-Si  ;,  r    '"r'  Z"''™'   ^'"'f^'i-'^   ^n 
Two  ot  the  aortic  se<rments  -ni  J"'^t  inside  the  auricuh.r  mircw! 

the^corponwUantii.  ^  "'"''  '''^"  ^"•^■^-'^^^'  '«"ad-like  vegetatbns  bSow 

-corsev^re^S^k  Sjlf  f/fci^' f  V"  ^^'^>''  ^^^O-  -'i  a 
''«n-t  murmur.     About  the '^Otli  of  ?t      ^^'"\„^^"  rheumatism.     X 
«'«ce  and  on  March  ;Jd  he  4  in  l"^  »  "  j;;";-}'  ^^^^'  '^^^  ^^-^  -  '•ecur- 
Br.  Molson.     About  tlie  JOth  he  it'^"     I     ^''"^  ^'"''■'''^'  ''«spital  to  see 

-stless.  On  ti.e  Hth  the  tem^rV  !""{  ^'^'^^'^^  and' extreme  , 
I'ame  comatose      TI.p  l«tv  „    '"P*''inne  rose  above  104°  J^'    .,nri  i.^  i  ' 

were  constantly  tJll^i^.  "Suhn'tK"'^'  ^''^  'i' '  -''' '  W 
fl'e  K'th.  The  autopsy  showed  vV.  H'' ^hed  on  tl,e  mornin-^  of 
vegetations  large,  soft,  gray?^   hten  ?,?'''' V" '''""'   valvulitis,  lie 

il'e  brain   and   membranes   he-ilthv  ,  -1     1      '^  ™any  recent  in^ircts 

e..^'Hosf>!'d,  mldrDJrS:!,.:^!:^";;^?^^^^'  ^^  "-  ^f-t-al  «on- 
-n  There  ..is  no  rheumatS;;^^;.^ die"  m!  ^f  ^?/^J"  ^''^^'^  «f  ^^^J-^us- 
<l!  ys  before  admission.  Here  ion  Ih  ]  ■  '"'''  ^"^'owed  a  fri<dit  five 
nntral  valves-a  ro^v  of  sof  wa  rt^ot;?/-'  ""^'"'"^/^"^  '^■•^'""  ^vas^n  tie 
within  the  free  margins.  '  vegetations  on  the  auricular  face  just 

0^  Guy's,  Barthoio,::^:::  T^:^":;;!  ^  r^'"^''  ^^-^^ 

•^tnrges  states  that  there  were  only  five  ivi  h    Ik   i        rf'   """^P^'^^^' 
cardium  reported  healthy  '"^  '"''"'^  ''''^'^'es  and  peri- 

1  ime  found  the  reports  of 


additional  cases,*  which,  with 


the  th 


ree 


-  Clioieu.     Luudoii,  IS81. 


I 

t' 
I 

1 


u 


374     OSLEH,    THE    CAKDIAC    RELATIONS    OF    CIIOUEA. 

here  given  makes  18,  iu  10  of  which  there  wa^i  initrul  endocarditis.  W,- 
may  say  that  of  11-3  fatal  cases  of  cliorea,  witli  notes  of  the  state  of  thr 
heart,  in  not  more  than  10  wn.w  this  organ  found  normal,  and  in  the 
great  proportion  of  the  cases  the  lesion  was  acute  mitral  valvulitis. 

One  other  point  must  be  considered  before  we  speak  of  the  nature  ni' 
the  heart  nnirmur.  In  what  proportion  of  the  cases  is  there  a  history 
of  rheumatism?  In  35  of  the  I'JO  cases,  29.1  per  cent.,  there  was  a  untc 
of  articular  atlection,  either  acute  or  subacute,  or  of  pains  which  miglu 
be  regarded  as  rheumatic. 

Much  has  been  written  in  explanation  of  the  heart  nnirmur  of  chorcn  : 
an  idea  of  how  much  may  be  gathered  from  the  fact  that  a  discussion  of 
the  theories  which  have  been  advanced  occupies  twelve  pages  in  Haydcn's 
work  on  Dkeoncs  of  the  Hrart.  We  are  concerned  chiefly  with  the  apex 
systolic  murmur,  universally  recognized  as  the  most  frequent  and  cliar- 
acteristic  sign  of  implication  of  the  heart  in  chorea.  Speaking  geiicnilU . 
we  meet  with  such  a  murmur  in  mitral  endocarditis,  or  in  relaxation  of 
the  ventricular  walls,  such  as  occurs  iu  amemia  and  fevers,  and  it  is 
attributed  to  regurgitation  through  the  mitral  orifice,  owing  either  to 
absolute  insufficiency,  in  conseipience  of  the  endocarditis,  or  to  rehitive 
insufficiency  when  the  normal  valves  arc  unable  to  close  an  orifice  en- 
larged as  a  result  of  relaxation  of  the  heart  muscle.  In  cliorea  a  special 
theory  of  nnisculo-jiapillary  spasm  has  been  advanced  to  account  for  the 
mitral  nnirmur. 

It  would  be  fruitless  to  re-discuss,  in  all  its  aspects,  a  subject  so  well 
and  ably  presented  in  various  works,  particularly  in  those  of  Ilavdeii 
and  Hturges.  That  thei'e  is  such  a  condition  as  spasm  of  the  papillary 
muscles  resulting  in  a  "want  of  correspondence  between  the  fibres  of  the 
ventricle,  which  obliterate  the  cavity  and  those  which  (;Iose  the  valve," 
is  a  j)lausible  hypothesis  unsupported,  so  far  as  I  know,  by  any  clinical  or 
anatomical  facts,  while  the  general  immunity  of  involuntary  muscular 
organs  in  chorea  speaks  strongly  against  it. 

Sturges  thinks  that  there  may  be  a  fatigue  paresis  of  tlu;  i)apillary 
muscles,  similar  to  that  which  sometimes  involves  the  limbs,  and  this 
weakness  and  relaxation  prevent  accurate  adaptation  of  the  valve  seir- 
ments.  He  urges  iu  support  the  inconstant  character  of  the  nuinnur, 
appearing  and  disaj)pearing  without  api)areut  cause,  and  states  that  it 
may  be  synchronous  both  iu  its  time  of  arrival  and  duration  with  the 
paresis  of  the  voluntary  muscles.  I  have  not  been  able  to  trace  aiiv 
such  connection,  nor  have  I  found  in  the  i)aretic  cases  any  special  ten- 
dency to  variability  in  the  murmur.  Indeed,  so  far  as  mv  ex])erient'c 
goes,  the  apex  systolic  bruit  of  chorea  is  by  no  means  an  inconstant  nnir- 
nuir.  If  muscular  incompetency  has  anything  to  do  with  the  production 
of  the  choreic  bruit,  it  is  more  likely  to  be  of  a  similar  character  to  that 
which  occurs  in  anaemia,  debilitv,  and  fevers.    Here  it  is  the  relaxation  of 


CIIOUEA, 


--..ia.  and  i„  .  contain  propo.;- .  '  .^i  'n:.  '  /^  f '  :'^'--  "^• 

1.S  di'tected  early  wh.n  there  i.  neith?...  •        '   '     ""^f»»«'f.s  the  hruit 

I  am  strongly  of  the  o^il  „    Hat  r;;:""""^'^''''^^-- 

7-' ^v ,/....,  .0..!:;;:;;;;;  t::;;'r  tr  'f''  '""'t''^  "- 

show  it  i.  exeeptional  to  fi„.,  t,,  he.irt  t  -U  1  T'  "'V'""^^^^ 
.tat.st.c.of^u>y  verylaryenun.heroffat'.  H^  f-  V  ""'  ^"'*"' ^'^" 
'-t.s.n  to  ph,ce  heside  these  ii..,re  "7   '  ""'"■'"''  '''•'^'- 

-so  prone  to  endocardial  eonmli^t   ,  , '   'm         "  '''"   '^"'^  ^'^^»«^' 

this  respect.  Dh-ldnson  has'  ^  h^  r  ""T"'"'  "'^'^  ^•''-^"  "> 
"•"■i"  --  not  rather  Jtu^^^rT  "■'"■^''-- ^'-- ^-.l^  of 
defect,  and  Stnrges  holds  tin    tl  '"  ''"  '''""'  "^"  ^''^^  ^''''vular 

i"«an.,nation  o^the  endll^.^^  '''^X^ir '  7^^'^"  ='  ^^^ 
"ot,  I  think  it  mnst  be  conceded  that  thll  •  '"«'""-'alion  or 

-llyns  nell  as  nnu-roscopica  Iv  Ji    ,  ""  ''  "''"''■^''^^'  n.ieroscopi- 

see  it  in  other  diseases  '  '  "'"''''  '"'  '''''>■  -^'ocarditis  as  Ive 

-•  Tho  character  and  loeitlon  nf  fi, 
i".-her  af^ctions  has  tau^ir^a     ^:ZZZT  "'  '■''''''- 
■>"tnil  segn,ents.      I  speak  of  the   a,ex  t  '"""""""f"'"  "^  M'e 

^'""■Id  be  so  gencraliva.sociatc7.itM  '^''•'^"■""""•""•'•-  ^^hy  this 
-arty  vegetations  Just"  wit h^nt^-u  \  ^'■''™''  "^"  ^^  "'"•  "^'  ''""^" 
-  ->.,Id  think,  irion  :  ^;  :;^;:  ;r!-f  "^l^'-  -rtalns,  not, 
to  be  solved.  The  condition  crrfai2  doe  T  "":""''^'  '^  ''  l"''''>^-» 
->d  the  bruit  n.,v  perhaps  as  ht  b  >  "     "'''^^^'^''^'^  »-^'g".-gitation, 

t'"e  roughened  facJ of  thfCJ::,'""  "'«^^'^^^^^-  '^  "-  to  friction  of 

^uii^rnif  ,:t:  crer:  '■' "?----  <-  ^^^^ 

nu,st  acknowledge  that  the  bnu  .nu  f  'T,"''  '^"'  "^'"'-  ^'^^^^  "'^ 
-cossarily  accompany  n,U,.;l  "  ..^J^'t  7"^'  '"^-d'  ^oes  not 
>'PO'i  this,  and  there  have  been  f«. .       !  '  '''''"■'  "«"'  '"■"'•^ted 

of  chorea  in  which  tl     ve- '  ■  t  «     V'     T"V"  """^■"'^•^'  ^^•"''-'  --- 

-n.u;ation  tuiied  to  .::^r;:::s:;:;  r^r''-^""',^!^*'  --^^^ 


give  .'iuggest  that 
manifest  even  b 


we 


fl,im.,     The  facts  which  J  si 


Jiiay  .luring  tiie  attack  h 


lal! 


■:uhse( 


juently 


trouble.     The  d 


rheu 
siiiull 


inatisni 
egetati 


y  a  Tnurmur,  but  which  has  laid  the  found 
■ 'appearance  of  the  apex  ni 


ave  an  endocarditis,  not 


iitionof  futu 


too — has  been 


iirnuir  of  d\oi\ 


re 


ions,  thi.s  is  a  natural 


•ei)eatedly  followed,  and  if 


a— and  of 


sequence  of  the  cb 


m 


caused  by  the 
i'es  w  hich  go  oii 


I 

) 
i 

I 
I 

c 


I' 
s 

A 
9 


w 


■  * 


1  i!l 


ll'l 


37(3 


OSLKR,    TUK    CAKKIAC     RELATIONS    OF    CIIOIJKA. 


i ;!' 


I    ! 


■  '1  ...  I  .IM 


in  tlioin.  At  tir.-'t  a  soft  granulation  tissue,  they  become  in  time  firnici, 
smaller,  and  ultimately  sniootli  flat  elevations  mark  the  spots.  It  is  not 
imi)robal)le  that  if  we  could  follow  accurately  the  auscultatory  i.istory 
of  a  valve  affected  with  acute  endocarditis,  we  should  find  iu  many  ('a,«.(> 
that  the  nuirnuir  of  the  fresh  attack  disappeared,  to  reappear  when 
the  changes,  which  it  is  the  misfortune  of  the  acute  disease  to  initiate, 
have  reached  a  point  of  interfering  with  the  competency  of  the  valve. 

4.  In  its  sequel  the  cardiac  affection  of  chorea  has  been  sui>posed  to 
differ  from  that  of  other  disea.S(>s,  "as  none  of  the  injurious  after-conse- 
quences which  attend  endocarditis  in  its  other  relations  .  .  .  are 
found  to  ensue  here"  (Sturges).  A  study  of  any  large  lunuber  of 
choreics  some  years  subseciuent  to  the  disease  tells,  as  I  shall  show,  a  sad 
tale  to  the  contrary  and  proves  that  the  primary  heart  trouble  is,  in  u 
majority  of  cases,  at  least,  endocarditis. 

ir.  TiiK  Condition  of  the  TIkaut  in  Ciioukk'  r.vTiKNT.s 
SOMK  Years  aktku  tiii:  Attack. 

Owing,  doubtless,  to  the  difficulties  inherent  to  such  an  investigation,  this 
line  of  inquiry  has  not  been  followed  by  many  workers.  Indeed,  so  far 
as  I  know,  Dr.  Stephen  Mackenzie's  paper,  at  the  London  International 
Congress,  is  the  only  one  which  has  dealt  with  the  subject,  and  he  lia> 
examined  thirty-three  patients  at  periods  from  one  to  five  years  subse- 
quent to  the  attack.  Postal  cards  were  sent  to  all  the  jhoreic  patients,  in 
sets  of  twenty-five,  who  had  been  in  attendance  at  the  Infirmary  since 
187(5,  asking  them  to  return  for  the  purpose  of  having  the  heart  exam- 
ined. One  hundred  and  ten  came  back,  a  luimber  much  exceeding  our 
expectations.'  All  the  more  recent  cases  in  attendance  at  the  clinics 
have  been  excluded— all,  indeed,  after  j\Iarch,  1885,  so  that  tlu;  stu.ly  is 
based  upon  110  cases  in  which  the  examination  was  made  inore  tint  ii' I  in, 
years  subsequent  to  the  attack  of  chorea.  In  each  case,  as  it  came, 
reference  was  made  to  the  original  notes,  questions  asked  concerning 
subsequent  attacks,  and  rheumatism,  and  the  heart  examined  in  the  re- 
cumbent and  erect  postures,  at  rest  and  after  exertion. 

The  results  summarized,  are  as  follows:  In  4:3  cases  the  heart  was 
normal,  in  ')4  there  were  signs  of  organic  disea..e,  and  in  13  there  was 
functional  disturbance. 

Tne  tables  which  I  have  i)rei)ared  are  too  full  for  publication,  but  the 
following  abstracts  of  the  cases  affected  will  be  of  interest : 

1871  (sixteen  years).     Two  cases. 

Case  I. — Laura  C.  K.,  aged  twenty-five.  Several  attacks  subse([iient 
to  1871.     Never  had  rheumatism  until  February,  1887.     No  note  of 

'  It  spciikB  wfll  for  tlio  stiibility  of  the  artisan  class  in  I'liiiiulclpliia  that  so  many  of  the  iiostul  cards 
reached  their  ilestination.  Coiiiiiarutively  few  were  returned  from  the  VoBt-oHice  with  tlio  coniinent- 
Semoieil;  cannot  find. 


CHOKEA. 


ski'd  coneoriiinf,' 
mined  in  the  re- 


"'""■■■"""-^""- '-■-".,..  „.,„„,.„,, 


iioiirt  condition  in  prcvio.,,  uKm-I.-  • 


'Ml 
.       -..„.   -...(M.isi;  IS  i„n.||,|..       i!"P'''"r'^^"^"-'^l><>Hne.sMof  |)r(...fl, 

'""■r  ri^ I-'*""'- r"'- : «    s::.:;:;n-t  ■^'" ' *"' 

'  I't-Miui  jfit  accen- 


^'"  liean  aniTfion. 


l'^"2  (fift,.e„  years).     One  ease. 
m4  (thirtoc-n  year.).     Three  oases 

^li'lness.     .Second     fr       '•"'''  ^'';  '"  I'^lmcarv  a  va      V^-  ''  '^''^""^ 
'31-Lona  Jen  accentuated.  "'.^  aiea.     ^No  increase  in 


1875  (twelve  vears^      T,,-.. 

K  yeai,).     luo  cases ;  one  norma). 


attack  very  severe ; 
-^0  note  of  heart  in 


"""•-"••     Loud  aclentuatidt-oni  IT"'"  ^'"■'"  ^  -"^''  l-iSt 

^^.Ce^venyears).     Eight  cases  :  one  norn.al. 
"j  ^^«^,     >^o  ^eumitiLnr^^^^SK"-     ^'r  ''''  three  attacks  last 

«,■««;  impulse  feii","„  tS"T""'-'  ^  "*'«'"  ^'"l"  '« ft' 


r 
) 
i 

I 

t 
c 


.1 


I' 

3 


.;f 


•^ 


/ 


378     OSLKK,    TIIK    CAUDIAO     HKI.ATIOVS    OF    OiroKKA. 

<'xerti(>ii  loiKlor.  Botli  very  <li.stiiiL't.  Socoiid  left  very  loinl.  lias 
occusioniil  attacks  i)t'  palpitation. 

Cai-.k  XII.— Ida  L.,  ai,'('(l  (iiirlitwii.  Tlirt'o  attacks  since  i>*7(!.  Is'd 
rh.'iMiiatisiii.  No  note  iif  iicart  in  I'S?'.'.  No  symptoms.  St,ihi.-<  jinisni..-  : 
Beat  i'orcihle;  dnlnoss  increased.  Lund  a|)ex  systolic  imirmnr,  iicani 
at  angle  of  scapula  and  very  distinct  alon;;  lel't  marjfin  of  sternum.  .\i 
aortic  cartilage  a  .--oft  systolic  hrnit.  Second  left  'inging  and  acciii- 
tiiated. 

Cask  XFV. — Jennie  A.,  aged  twiMity.  Second  attack  in  1M7><,  lliinl 
in  l-'^7!*.  Xo  rlieumatisni.  In  I  ^7!),  sound,  stated  to  l)e  normal.  Shihi^ 
prie-vHs:  Impulse  not  forcible,  no  apparent  eidargement.  In  fourtli  let'i 
space  a  rough  p'.osystolic  murmur;  iimiled  i'l  ari'a.  At  a|)ex  a  systolic 
bruit,  traiismitied  to  axilla,  and  lietird  at  iMigle  of  scapula.  Second  li  It 
v^ry  accentuated.  Sounds  at  apex  booming.  No  symptoms,  always 
good  health. 

("ask  XV. — Annie  L.,  aged  twenty-four.  Two  attacks  since,  last  one 
in  D^I^'I,  when  for  the  first  time  she  had  rheumatism.  No  note  of  heart. 
Stutu'^  pni.-ifii.-* :  A])ex  an  inch  outsidi'  nipjde.  Impulse  forcible.  No 
thrill.  I'r  .systolic  murmur,  not  rough,  in  fourth  space;  apex  systolic, 
heard  in  axilla  and  r'  angle  of  sca|)ula.  Loudly  accentuated  second 
left.  Has  had  palpitation  and  shortness  of  breath  on  exertion  for  three 
years. 

Cask  XVI. — ]\Iiriam  C,  aged  nineteen.  Two  attacks  since.  Never 
had  rheumatism.  Has  had  heart  disease  for  some  years;  is  now  in  bed 
with  it. 

1877  (ten  years).     Seven  cases;  three  afected. 


Cask  XVII. — Andrew  G.,  aged  twenty-one.  The  attack  followed 
acute  rheumatism.  In  1878,  a  soft  systolic  murmur.  No  symptoms. 
Stnfits  pncseiM :  When  recumbent  sounds  clear.  Erect  and  after  exer- 
cise well-marked  a])ex  systolic,  not  transmitted.  Second  left  ringing, 
accentuated,  and  reduplicated.     No  enlargement  of  the  heart. 

Case  XX. — Mamie  L.,  aged  fifteen.  Rheumatism  (acute)  four  weeks 
before  onset  of  chorea  in  1877.  No  attack  since.  In  li^77,  "  mitral 
murmur."  Xo  symptoms.  Stutux  pnrxeit^ :  Impulse  forcible,  beat  out- 
side nipple  line.  Transverse  dulness  increased.  Loud  apex  systolic 
nuir;nur,  ])ropagated  to  posterior  axillary  fold.  Second  left  very  accen- 
tuated. 

Case  XXIII. — Rose  ]McF.,  aged  twenty-four.  Attack  in  1^77  pro- 
longed and  severe;  none  since.  Ko  rheumatism.  In  1877,  a  faint  apex 
sy.stolic  murmur.  Statux j)rcE-'*e)h'< :  Heart's  action  violent;  impulse  for- 
cible ;  apex  outside  nipple.  INIarked  presystolic  thrill.  Presystolic  nuu'- 
mur  in  fourth  interspace.  Systolic  murmur  in  fifth  space,  and  heanl  as 
far  as  posterior  axillary  fold.  Second  sound  accentuated  at  the  secniiil 
left  cartilage,  and  al.so  heard  loudlv  in  axilla.  Patient  is  at  times  very 
short  of  breath  ;  has  attacks  of  palpitation  and  has  fainted. 

1878  (nine  years).     Two  cases ;  one  affected. 

Case  XXIV.— Minnie  C,  aged  fifteen,  Attacks  also  in  187!l,  'f<0, 
and  '8").  Rheumatism  in  1885,  never  before.  In  1878  an  apex  systolic 
murnuir.  No  symptoms.  Status  /^rffw»,s;  Imi)ulse  forcible;  apex  out- 
side nipple-line;  transverse  dulness  increased.     Apex  .systolic  murnuir 


;':::<;'*>--  '•■ ■■a^.-. ».; .J;.:,,:,: '■ 

'""'  H...,;,,.;,;,.  i^nuishut  t'J^f'iv  "'^T!'--  ^"'•'""'  "•'"'•'<  in  l«.s.>     lln- 
t^  ..    Nopreviuus  not.M,nu.art  ,.;„£''  u'V-TT'    ^'>  '•'"•"'""- 

I         V^ 'T-        Jr-l'^Nt'lM-    (lllllicss    IIKTl'ilSt'd. 


l>"ii,ir|i  pmsy.^foiic!  tlirill.     \' 


'^7i'"*^^*;:Jv  A'>''f'*- '^'""..Is  ll,.|ILT  '^  '"^^  Hm.nt.,a...,l  a..,|  ,, 


iiiniii 

f  t''^;k.  Khoun.ati.s,„  i„  1^5  w  il  .i  '  .' ''  '"  ","":"'="T  ^vi,!.  a  s.v  .rJ 
l'>i.x  lm<l  swollen  joints.  I„  sil,:  fV  T  '"-'^""'=  ""*'  ^his  tine 
{"•"'7'--  I'"Pi.I,se  in  fifth  and  six   ,    n  si  ''  f'"^-\  """•'"".•.     -V.^' 

'^"";'  'M»>x  systolic  hrnit  |.n.|^a!^t  il   f    '   /''^'^l'-^-     ^^"'"^'■^^  i'HMvas<-d. 

No  note  of  heart  in  ^(^  u'^^l'T^'-'^T^'  ^^^>  ^•''-"atisn. 
"Yl'.and  at  tin.es  severe  pa,  Tl'^t'  ^''I'V^^^P'^'^tion,  shortness  of 
a  Id  tore.ble;  dnlness  increased  pt  V  .'.^'^^/'^r""''"-^"-'  ^^ction  rapid 
i;H.^h  presystolic  nu.rmn)^  Sok  sS'l  "'"  ■  '"'''^  ""  •»^'^'-  ""tral  am 
1^  -  loud  but  not  speciall V  a  een^  nt  ,]  F  ■'"'•  ''''}'^^^  ^V^--  '^oeon  1 
er  a  course  of  iron  and  a  5  ic  v  iV,/f 'V'"'';'  "^^'i"  ^"■'H'  weeks 
'ainnursunehanir..d.  '  ''''"''   '"'^^   •'olieved  the  anaemia- 

^  <^Asi.:XXXIli._An.rek  W    .,      i    •  , 
{r;t  i"   1880.     Xo   rhe,Si^,i:    fti:^]^']^^''''-  f  "'^^^^  ^'^  t'- 


I 

increased  on 


<'eiitiuue( 


ASK 


exertion;  not  altered  ! 

xxxrv 


Vvx  systolic,  heard  as  f 


>y  position. 


•Fl 


ii'\as  middle  axilla,  and 
'^■••ond  lett  a  little  at 


f-thcatt;;i:.-i;,'?S;;; 

"^■a  occasional  attacks  of  pal 


tl 


jipex  a  little  out,  but 


•Pjice  B.,  aged  twenty.    Ill 


an  a 


vlieuniatisni  si.v  months 


ptx  svstolic  murmur.     Uas  1 


pitation.    Sfdfu. 


ad 


•pncscns:   Impulse foreibl 


=inice 


,' •-"^■iJ«  our,  out  nosoeci'il  o.>I.,,.  "wi^«««.-   inipn 

heard  well  to  n.iddle  axilT    M,,?.  !i'  P'"*-^"*-     .^P^'-^  ^^.V^^ 'ul 


'11a.     Marked  accentuation 


of  second  left, 


10  murmur, 


( 

i 
I 
) 
1 

< 


) 
I 
) 
i 
I 

V 
D 
1 
I 

I' 

;< 
) 


n 


w 


!  I 


4 


380     OHIiER,    TFFK    OA  I!  DF  A  C     H  K  I,  A'l' I  O  NS    OK    (UIOUKA. 


t  ■• 


I    I 


n 


IMMl  (six  years ).     Sixteen  ciiscs  ;  nine  atlected. 

('asi:  XXXVI. — Ltiiiis  ().,  iij,'eil  sctventoeii.  Al  least  live  attaekr^ 
siiieelSSI.  No  I'lieiiiiiatisin.  Nu  iiole  of  heart.  Xo  svinjitoiiis.  St(ilii,< 
jiiiiMrn/<:  .\|iex  l)eat  in  ruiirtii  space  in  iii|i|)le  line,  lieaviii;;  ami  Hh- 
cil)je  ;  (liiiiK>s  iiiei'en.sed.  Loud  systolic  miirimir  at  apex  iieard  to  po.- 
terior  axillary  fold,  hut  not  ahove  Coiirtii  space.  Wlieii  reeurnhciit  it  i- 
lieard  in  st'cond  and  third  spaces  as  well.  Second  left  very  accentuated. 
('asi'.  XXXIX.— Frank  N.,ai;-ed  thirteen.  A  .second  a'ttai'k  in  l.s,s|. 
Xo  rheninatisiM.  Ileiirlsaid  to  have  heen  normal  in  1M84.  I'or  some 
time  has  heen  very  short  of  hreatli,  and  L;cts  tired  on  exertion.  .SV-(/((,. 
jmiwHn:  Preeordia  hiilues.  Inipul.se  diliii.-<e;  dulness  increasi'd.  Vw- 
systolic  thrill  in  fourth  interspaet".  .V  hluhherinj^'  [iresvstolic  murmur. 
Maximum  intensity  in  foil rt h  space.  Jioud  hlowinjf  systo)ie  hruil;  heard 
also  in  axilla.     Very  accentuated  second  left.     Aortic  second  feehle. 

C.V.si:  XL. — William  1'.,  aged  twelve.  Secoii.!  attack  in  188:1,  third 
in  188."».  Xo  rheumatism.  Condition  of  hcaii  not  noted.  lias  ni> 
symptoms.  Slalii.-<  ;;/vr.sr«.<;  J)itfu.-<e  apex  heat  in  nipple  line,  in  fourth 
and  fifth  spaces.  Transverse  dulne.ss  increased.  In  erect  |)ostnre  souiid> 
clear.  Iie(Mind)ent,  distinct  ajiex  .systolic  murmui'  transmitted  alun- 
anterior  axillary  fold.  In  third  and  fourth  interspaces  doid)le  murmur. 
the  diastolic  not  rou;;h.     Socoml  left  very  nnich  accentuated. 

('A«r,  XLI. — Jose|)h  .M  ,  ai^ed  thirteen.  First  attack  January,  iNS]  ; 
second,  Octoher,  1881.  No  rheumatism.  In  18S1  asoft  svstolic  nuir- 
nnir.  Ifas  had  vertigo  and  rushes  of  hlood  to  head.  Slu'tiis  /)riiniii'< : 
Impulse  iiot  forcible;  dulne.ss  slightly  increased.  No  thrill,  hut  loud 
shock  of  first  sound.  Kinnhling  j)re.sy,stolic  muriiHir,  maximum  in  lifth 
space  in  nip[))e  line,  is  \\.  11  heard  to  anteri(U'  axillary  fold.  Louilh 
aeceninated  .second  left.     No  systolic  murmur  even  when  recundient. 

C.v.si   XLIL— Carrie   B.,  aged .     Second  attack  in  J S84  :  third 

in  1881  i,  all  severe.     No  rheninatism.     In  1881  heart  normal.    No  .«ytu li- 
tems.    StdfiDt  /mrsrit.^:  Visihle,  sonn what  forcible,  pulsation   in  tliinl. 
fourth, and  tilth  spaces.     Erect  postui'e.no  murmur;   recumbent, sv.stoi' 
bruit  at  .-second   left,  localized.     Second  soun<l   here  loud,  sharp,  a 
redui)licated. 

Casi',  XLIIT. — Mary  B.,  aged  sixteen.  Three  or  four  slight  attack- 
since  1881.  In  1881  pains  in  joints,  no  swelling.  In  1881  an  ai^'x 
bruit.  Has  had  no  heart  symptoms.  I'^lafitfi  pnrnens:  No  enlargement. 
When  erect,  sounds  cleav;  recumbent,  systolic  bruit  at  second  left,  with 
marked  accentuation  of  second  sound. 

Ca.sk  XLV. — jNIarcus  Van  A.,  aged  eleven.  N(me  since.  No  rheu- 
matism. In  1881  a  somewhat  loud  nnisical  bruit.  No  symptoms. 
Status  j)ne)iens:  Apex  beat  in  nipple  line,  fifth  space.  Impul.^c  iioi 
specially  forcible.  Loud  blowing  .systolic  brnit  at  apex,  propagated 
to  axilla  and  heard  well  at  scapula.  Second  left  accentuated  and  re- 
duplicated. 

Case  XL VI. — Alice  W.,  aged  seventeen.  Second  attack  in  ls,S'_>. 
Pains  in  knees  in  1882,  and  lately  in  shoulders.  Heart  normal  in  J.^sl 
and  1882.  Srntas  pnvxens:  Soft  apex  systolic  murmur,  not  heard  iu 
axilla.  Second  left  accentuated.  No  enlargement  of  heart.  Has  at 
times  pal|)itation  and  shortness  of  breath. 

Ca.sk  XL IX. — Jessie  J.,  aged  nineteen.  Three  attacks  since.  Blieii- 
matisin  with  attack  iu  1883,  and  again  in  1885.     Heart  said  to  he 


(!|[()UKA. 


"Kl'lllill       ill       JiSrS,")  V  // 

"'"*  """•'•  I'ainai    tinu..  and  is 


pu 

lit  tht'   licart,"  liiiiK 

short  ofhrcatli 


l^"»^' .««>,,,„).    Tl,i„,.,.„  ,,„.,,,  „.„„„,„„„, 

;  ~" ;;':;;:;i:.'r- ■,  ''^"■'  '■' "'-"i"  ^^^'^tzir-  '"t. 

/  •    ""J'tiJ.M'  forcible.     Soft  Kvs(,,li,.  I      "      '/"  ■\^ "'  't'>'ii-s.     aSV«//(,,v 

vvASK  LIV  . — Iji.ssic  I'     ...    I  .1  • 


•I^MndMh^;^,,;^;,;!;;;'^^^^^    >..  HKHinnaisin.     Di,,]  ..n^art 

!"  1^«4,  ;:;f"^J;;j";;^  Ji^;^pt^loven.     Secon.l  attack  i„   Ins;]    n.ird 
'Finf?  rftliis  year     Zrl,^;-  "-?'  ""'l""'    A  socomi  ,V„H  •.tti.k  i„ 


*l 


:      ill 


I    i  Jl 


iijfi 


.,^^. 


n 


382      OSLER,    THE    CAKDIAC     RELATIONS    OF     CHOREA. 


I; 


:,  .f 


1 


increased.  Feeble  j)resyst()Iic  tlirill.  Loud  a])ex  systolic  niuriiu'.r,  pro- 
pagated to  axilla.  In  fourth  space  just  within  nipple,  a  riimhling  pre- 
systolic nuirnuir.  Secontl  left  very  accentuated.  Has  had  at  times 
severe  pain  in  heart ;  no  shortness  of  breath. 

188;>  (four  years).     Fifteen  cases ;  eight  affected. 

Cask  LXII. — James  G.,  aged  thirteen.  Second  attack  in  iScS"),  third 
in  188().  No  acute  rheumatism ;  ])ains  in  shoulder.  In  l8(S(j  a  systolic 
apex  murmur.  Status pne.'<ens :  Apex  outside  nipple  line;  large  area  of 
forcible  impulse  in  fourth  and  fifth  spaces.  Transverse  dulness  increastd. 
No  thrill.  High-pitched  apex  systolic  murmur  transmitted  to  axilla 
and  angle  of  scapula.  In  fourth  space  a  faint  runil)le  before  first  sound  ; 
second  left  accentuated  and  reduplicated.     Has  no  heart  symptoms. 

Case  LXIII.-— Tinnie  B.,  aged  twelve.  Ir^econd  attack  in  1(S(S4,  third 
in  1880.  No  rheumatism.  In  1886  well-marked  cardiac  lesions.  Sfatn-f 
pnrsenK:  Apex  beat  forcible,  outside  nipple  line.  Dulness  increased. 
Loud,  rough  apex  systolic  bruit,  transmitted  to  scaj)ula;  second  left 
accentuated  and  reduplicated.     Has  pain,  and  at  times  palpitation. 


Casi;  LXIV.— Henrietta  K. 


aged 


twentv-one.      t^econd  attack 


ICK     III 

1884.  No  rheumatism.  In  \)^H']  heart's  action  intermittent.  Stutns 
pravcn.i:  Beat  forcible.  No  thrill.  Loud,  rough  aiiex  systolic  briiii 
heard  at  angle  of  scapula.  Second  left  much  accentuated.  Has  great 
shortness  of  breath  on  exertion. 

Casfo  LXV. — Lorenzo  D'A.,  aged  eleven.  Two  slight  returns.  No 
rheumatism.  No  note  of  heart  in  188;].  Status  priesens :  Inijjulse  slon', 
forci!)le  ;  apex  in  fifth  space,  in  nii)ple  line.  Soft  apex  systolic  niurimir, 
louder  on  exertion  ;  not  heard  at  mid  axilla.  Second  left  much  accen- 
tuated and  reduplicated.     Has  distress  at  heart  on  exertion. 

Case  LXVI. — Nellie  H.,  aged  nine.  Second  attack  in  1884,  third 
in  188").  No  rheumatism.  No  note  of  previous  heart-condition.  Stains 
pru'xcu.'^:  Apex  beat  diffuse,  maximum  in  sixth  space,  one  inch  outside 
iiipi>le  line.  Dulness  increased.  No  thrill.  Loud  apex  systolic  murmur 
transmitted  to  angle  of  scapula.  Just  below  and  inside  the  nipple  a  fajl 
presystolic  bruit.  Second  left  much  accentuated.  In  December,  \XX{), 
the  child  had  a  sharp  attack  of  cardiac  dyspn<ea. 

Case  LXVII. — Edward  K.,  aged  twelve.  Second  attack  in  ]<SS,"). 
No  clear  history  of  rheumatism  ;  has  had  pains.  No  note  of  heart. 
Stains jii'dMeus:  IJeat  in  fifth,  just  outside  nii)ple  line.  Dulness  increased. 
Just  above  apex,  in  localizccl  regicm,  a  [)resystolic  murmur ;  louder  in 
recumbent  posture.  When  breath  is  hekl,  soft  apex  systolic  murmur. 
Second  left  much  accentuated. 

Casi:  LXXI. — Annie  C,  aged  eleven.  Bad  attack  for  a  month  ;  no 
recurrence.  No  rheumatism.  No  note  of  lu'art  in  IS.S;}.  Status  j>nrsni.^: 
Beat  at  nii)ple,  in  fourth  si)ace,  Transverse  dulness  increased.  Feehle 
thrill  above  apex.  Kough  presystolic  murnuir  in  third  and  fourth 
spaces;  heard  also  along  pectoral  fold.  Just  outside  apex  a  suf't 
systolic.  Loudly  accentuated  second  left.  Is  short  of  breath  on  exertion. 
'  Case  LXXIV.— William  H.,  aged  filteen.  Still  has  twitches  at 
times.  No  rheumatism.  No  note  of  heart.  Status  j)r(V-'<('us :  .Apex 
beat  in  nipple  line.  Dulness  increased.  Feeble  presystolic  thrill  at 
apex.  In  second  left  interspace  a  loud,  rouf/h,  systolic  murmur.  I:; 
third  and  fourth  spaces  a  softer  bruit.  Distinct  presystolic  ruinhle 
above  apex  beat.     First  sound  reduplicated  at  apex.     Second  left  iniicli 


;  H  O  H  E  A  . 


'^'^l^^'^/'^^-^-n  ease.;  ten  .ffectod. 


( 'heeks 


iire 


E 

■second   loft.      Xo  palpit-iTion""'  ,/^'"'/"3' ««^^'"itiiate(!  an 

apex  systolic  bn,it  propaga^  2  ^  Cf! -"^^  >!>  enlar.en>ent.    si^ 
"H'nnur  at   second    left   space  t  f         '°'"  '^•^''^''^'•3'  f-l't 

.\vniptoms.  ^  i^oiully   accentuated    left. 

P^-^n^i)^l^r'£;^^^^^^  ^0  otker  att 

inent.     Soft  nno^-  .„.,*.,i:„  ,      .!  "oiinal.     ,S/a//^9 


Systolic 
Ha.s   no 


r,     ;.  "    '^^O-*.        Heart    Tlnrm.,!  t.'j    J  "-"wj    .ULUCK.       ii'K 

.'>'ent_.     Soft  apex  systolic  hndt'T       ^M"^  prwsr,,. ;  Xo  enlar-e 
Case  LXXX.-Xclli.  M    .,     ■     ,  «•<'- '■Iml 


systolic 
faintly 


one  inch  outsic^3- nippie  i;;r-"S;;j-^^<;;^ble  ^P-  ^^^at  inlfth";'::" 
'oonung  and  echoing.     I„  third   m,  1   /•"',''•..    ^^^  ^P^x  first  s'un 
•nnt;  feeble  at  secMul  left   cil'  '^'^   '"^^  ^l'*'^'^es  l,>„d      '     "'' 

heard    in    mid-sternun  .       \r /^    '  'f '   "«1  "/''lil'le  in   axilla 
symptoms.  ^^"^''    accentuated    ..econd    left.      ir... 

tiS^T'""'  Lnpulse  j„.t  within  ,dpp^  ^;;;k  "'".'•"""•  "^  l^"^e. 
tlinl  At  apex  a  rund)lino.  prcsysto  p  >  '^''^"^'t"  '"ereased.  Xo 
audd)Ie  at  apex.    At  fourth  left^a.';''';''''"":;     ^^"  'y'''^^'^'  »>H.it 

fold." 


near  s 


roeumhcnt  a  soft  systoi 


nil>P'e  line.     First 


sound  at  aj)ex   b 


*r„„„,.  .¥;„ri^:ffr:,:':™r "'.  r-"  -..i  .iiis  i.* 


-::Sx^{!ii«"iri-?"!':'-i 


loonuni"'. 
spaces 


"'»i'"ial  in  1««4.     AW,/ 


i)ft. 


long,  ape 
'"I'd  spaces.     Di 


,  aged  twelve.     No  rlie 


mp>^,r.^i,^,n<< :  No  onl 


X  systolic  nni 


'•"iiir,  not  hoanl 


i'l-gement.      \\'1„,„ 


.iimatisni.     Heart 


and 


in  axilla 


recumbent 


^appears  when  erect.     Second  \J        !  ,'"'  ',"  '"'•""'  "»' 
acr./^.,,)  ......i,  "^^'-^Jnd  (lull  aiK     (iiK    ii,.f  „i 


'•"'ging,  like  second  riirht 


md  loud,  not  sharp 


1 

I 

) 

J 

) 

I 

c 


;  t 


'1  >    : 


ri 


: 


1*1};,    h 


381     OSLEK,    THE    CARDIAC    RELATIONS    OF    CHOREA. 

Case  LXXX VII.— Fannie  P.,  aged  ton.     Second  attack  in  ISHf). 
Pains  in  wrists,  but  no  swelling.     In  18S.")  ai)ex  nnirnuir,  prcsy.«tolic  ; 
.soft  basic  mnrnuir;  hypertropliy.     Stiitii.'<  pnmmii:  Forcible  ai)ex  beat 
in  liftji  space,  outside  nipple.     Feeble  thrill.     Loud,  liigh-])itched  apex 
systolic  bruit,  transmitted  to  scajjula  :  and,  in  fact,  all  over  left  chest. 
Presystolic   bruit.       At    aortic    cartilage   a    rough,   svstolic    muruuir 
Second  left  accentuated.     Has  palpitation  at  times. 
_  Cahk  LXXXIX.— Annie  T.,  aged  thirteen.     Several  slight  returns 
suice  1«84.     Ilheuiiiatism  three  months  after  the  chorea.    No  note  of 
heart  in   1884.     Statiti^  pniwiis :  Action  rapid,  apex  a  little  out  from 
nipj)le  line.      Dulness  increased.     Loud,  rough  systolic  l)ruit  at   apex, 
transmitted  to  scai)ula.     Second  sound  verv  accentuated  at  third  left 
cartilage.     Has  "  spells"  with  her  heart ;  has  fainted.     Is  short  of  brcaili 
on  exertion. 

1885  (two  years).     Eighteen  cases  ;  five  attected. 

.  Case  XCI. — Lizzie  E.,  aged  fifteen.     No  attack  since.      No  rheu  > 
tism.      No  note  of  heart.     Sfatun  prcenens :  Impulse  strong.     Thr''i  ,r, 
upex.    Localized  systolic  murmur  at  apex,  not  heard  in  axilla  v^r  ;.>; 
third  or  second  spaces.     Loudly  accentuated  .second  left. 

Case  XCIL— Alice  N.,  aged  ten.  Xo  rheumatism.  In  188.")  loud 
mitral  systolic.  Stain.-'  j)nrsens :  Apex  beat  diffuse  in  fourth  and  ti ft  h 
spaces  in  nipple  line.  Transver.se  dulness  increa.sed.  Apex  .systolic 
murmur,  lieard  beyond  mid-axilla;  intensified  in  recumbent  posture. 
Marked  accentuation  of  .second  left. 

Case  XCVIL— William  R.,  aged  nine.  Xo  rheumatism.  Heart  in 
1885  said  to  be  normal.  tStatua  pnescns:  No  enlargement.  First  soiiiid 
not  clear,  and  on  exertion  a  soft  systolic  murmur  at  apex;  heard  also 
two  inches  beyond  nipple,  and  as  high  as  third  rib.  Loudly  accentu- 
ated second  left.     Has  no  symptoms. 

Case  C— Georgie  G.,  aged  thirteen.  Xo  rlieumatism.  In  18,s:)  a 
basic  systolic  murmur.  Sfatus  pnmenx:  Impulse  diffiise,  forcible  ;  apix 
just  outside  nipple  line.  Dulness  increased.  Thrill.  At  apex  loud  svs- 
tolic bruit,  propagated  to  posterior  axillary  fold.  Second  left  dull,  thud- 
ding, and  accentuated.  Heart's  action  irregular.  Has  palpitation  niid 
shortness  of  breath. 

Case  (T.— Jennie  X.,  aged  nine.  Second  attack  in  188(),  in  wlurh 
she  had  rheumatism.  Heart  in  1885  normal.  In  188()  loud  ai)ex  sys- 
tolic murmur.  Stutn><  pra'sciix:  Impulse  forcible,  apex  in  nipi-le  liiic. 
Dulnc-s  increased.  Apex  .systolic  transmitted  to  axilla  and  an^dc  of 
scapula;  heard  also  as  high  as  second  rib.  Second  left  loudly  accvulii- 
ated.     Has,  at  times,  throbbing,  palpitation,  and  pain. 

( )f  the  43  cases  in  which  the  heart  was  found  normal,  1 2  had  h;i(l 
three  or  more  attacks,  8  had  had  two,  and  T.\  a  single  attack.  Tliero 
was  a  history  of  rheumatism  in  8—/.  e.,  18.()  per  cent.  In  (5  of  these 
cases  the  rheumatism  was  acute.  In  only  2  cases  had  there  been  a  iniir- 
mur  noted  at  the  time  of  the  original  attack. 

From  the  cases  presenting  abnormal  physical  signs,  1;>  may  be 
separated  as  exam])les  of  functional  trouble.  They  are  cases  without 
signs  of  enlargement  of  the  heart  and  with  localized  or  variable  iiiiir- 
murs.     Ten  presented  soft  apex  systolic  bruits  not  ])r()pagated 


ni 


CHOHEA. 


vai-ml,lo  „i,|,  |„„ii;„,,     i„  „,^,j 

.>»coii,I  left  imhmmyy  sound  l,,„  r  ,1  ""'ontiiali f  ,|,„ 

'" ""™-'  1—'^.  i'--tic„ia;a'„o,„i„,; "J :, T :;;■  ;;"■"'" '."'"'"«" 

osaiiHiiatio.1  of  „1|  ,||„  .  ,  '  . '"  I""'  "i  tins  ]>„i„t    „  (|io 

'"  -Lioh  the  pulrnonarv  sound  w  dW  .cth^'T  "T  ''  ""■""^'  ^^^^ 
in  some  instances  mluplicated  N,  ,t  ^  f'"  ''"'"  ^''^'  '""•^'"^^  »"'l 
often  developed  in  the  re^don 'of  tlu  1  '  '"'  "^'  ''"  "'"'■'""■•«'  «'> 
•i'>"  ""'J  "hich  are  ex.ro.n    v  J"''"""'''''.^- artery  during  respiru- 

oases  the  sounds  in  U'     Z,  :'"";"  "!  ^''--''-ted  d.ild.^n.       „  2 

--"bent  position  .-s::;:':;  ^  d^i  LT  ti  ':r''  ^-^  -  ^^- 

was  aocenluated,  and  in  one  the  -17  r      ] '  *'^'  ''^'^"^  «^>i'»^l 

In  a  third  ease  there  was  a  sof  sv'    oil       '  ■'  "'"^"'^'^^  '"-"^^^^d- 

^I-s  in  the  .ecu.bent  ^S  hi     tV:;;^::"' ^^  ^?-"^ -''' third 
"'-'"ary  sound  and  the  apex  hea    o      M  ^^ '^^"'uafon   of  the  p«l- 

tl.-  there  n.ay  have  hee    or '  u  e  cl     l  '  7'''  ''"■•     ^"  -'"'  «f 

■>  '>-t  to  exchuk  all  doubtful^'rs  '"  '"    '"  '''''''  '"'^  ^  ''-'"^d 

i"''^::.::;^  ;:,r;t:rr^  ^^'^^^  ^1'^ '--  -^  -•-  disease. 
Ti.e..ets.e,ardin,z;:;;;i:  ::;:::::t'7 

wat.,  li.ere  Mas s,i„„  l,i.„,„,    ,     "."■"'"•-•    '"  ^'^  ™aes,  40.7  ixa- 

'■""'I«'""S  tlio  frB|„cuov  of  rl„.ui„.,tic  ..fli-f"  ■™"'',  ■'"'''■  ""  """='"• 

o™..,-viei,  ti,„,  i„  ,1,0  ,„.,„  „„x  f!  :^^"'; -;■;'''''*•'■■""'>•-'''■■  I- 

t" 1>  of   4;l  „„n„„|  „,„j,    J.       „,.'''*■■'"  !»'■«»«.,  or  will,  tlic 

*-o  corcisos  i„  ,.,.„<,„e;„,  n,^';:!,::",  tir;  "Vo"„:;""r'"  "■■■' 

<'h'  larger  proportion,  oD..^  per  cent    nf  H  "    •  ^^'  ^">^\"evcr, 

^•'"'^""atic  trouble.     Of  th      M    "  "'        ":  T?  "'^''""^  ""•^'  '''^^orv  of 
attacks  of  chorea,  only  7  hadTheu^'i^;!"  '"'   '"'""  "'  "-- 

^^•th.eference;o^hr:.;!;  :^'::;::^';-^-.of-- 

--«  of  uncon,plicated  n.itral  affee  iL  Id  4  """'  "'""'  '''''  ^^ 
aortic  and  nutral  disease,  h-  •>' ili^Hh;  ^  "  "'"?  "^'  """'^'"^d 
">'"•;  i"  17  a  distinct  presvstolL  Z  •?'  ''  """'''^  ^^>''^"''^'  '»"»- 

--"y  -ith  a  systole  ^Q  ''r'"' 7^''';^''''''''t  a  thrill,  and 
rented  a  soft  aortic  direct  n  u-nun  "'       ,^'"""^  ^'"^^'  ^"^'U-  I"'^' 

adouble  aortic  n.unZi:::^2  Ti^;::^'^  Tt '  ''''' '''^^■ 
^"'■^'"'f  --tio  and  antral  dis^^  cl  >  XXX h"  '^''- ''?' ^' 
aaa.ual   combination   of  an  aortic  d hV  l     ^^^  l»''^^«^"tcd  the 

— ur.     The  overwlKdnunV       ;,'    :  tf    '"'  ''  -'f  ™^  '^^^■■^^'«^«'- 
'«  what  we  might  expect   f^Ln  '-''^^cs,  w.th  nn'tral  lesions, 

endocarditis  of  ;henn,S.  ^:^J^::::^^  ''"''  f''  '''  ^"^^ 
NO.  cwxxvni.-ocTOHKB,  1887.  ^""'ea  attacks  these  valves 


'       I   ■ 

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i 

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386 


DANA,    HEREDITARY    TREMOR. 


There  are  mjiny  points  of  interest  in  pliygical  diagnosis  which  these 
cases  ilhistrate,  but  I  am  only  concerned  now  with  the  clinical  problem 
of  the  frequency  with  which  organic  heart  disease  follows  chorea. 

Not  many  of  the  oases  had  subjective  symptoms  of  cardiac  disease. 
In  14  instances  there  was  complaint  of  shortness  of  breath  ;  16  cases 
had  attacks  of  j)alpitati()n,  and  in  6  cases  there  was  cardiac  i)ain.  Two 
cases  had  died  of  heart  disease,  1  was  in  bed  with  (•ardiac  dropsy,  and 
in  several  others  there  were  premonitions  of  heart  failure.  The  miijorily 
illustrated  the  important  clinical  law  in  valvular  disease,  that  the  symp- 
toms do  not  result  from  the  lesion,  but  from  failure  in  the  compensatory 
action  which  for  years  may  eciualize  the  circulation  and  obviate  coiu- 
pletely  the  most  serious  mechanical  defect. 

A  study  of  these  cases  justifies,  I  thiidv,  the  following  conclusions : 

1.  That  in  a  considerable  proportion  of  cases  of  chorea— much  larger 
than  has  hitherto  been  supposed— the  complicating  endocarditis  lays  the 
foundation  of  organic  heart  disease. 

2.  In  a  majority  of  the  cases  the  cardiac  affection  is  independent  of 
rheumatism,  and  cannot  be  regarded  as  in  any  way  associated  with  it; 
unless,  indeed,  we  hold  with  Bouillaud,  that  in  the  disease  "chez  ies 

jeunes  sujets  le  coeur  se  comporte  conmie  une  articulation." 

3.  As  the  presence  of  an  apex  systolic  murmur  in  chorea  is  usually 
an  indication  of  the  existence  of  mitral  valvulitis,  as  much  care  should 
be  exercised  in  this  condition  as  in  the  acute  endocarditis  of  rheumatism. 
Rest,  avoidance  of  excitement,  and  care  in  convalescence,  may  do  much 
to  limit  a  valvulitis,  and  obviate,  possibly,  the  liability  to  those  chronic 
nutritional  changes  in  the  valves  wherein  lies,  after  all,  the  main  danger. 


HEREDITARY  TREMOR, 

A   HITHEHTO  UNDESCRIBKD  FORM  OF  JfOTOR  NEUROSIS.' 

By  C.  L.  Dana,  A.M.,  M.D., 

PRESIllKNT   OF  THE   NEW   TOnK    NEUKIU  OIIICA  L   SOCIETY,   VISlTINa   I'flYSrCIAN   TO   BFLLEVIE   HOSVITAL, 

PltOl-ESSIlIi   OF   NEUVOl'S   AM)   JIENTAL   DISEASES,    NEW    YOKK    POST-UHAUUATE 

MEDICAL   SCIIOOI,. 

Thk  object  of  this  paper  is  to  call  attention  to  a  peculiar  hereditary 
motor  disorder  whic'i  has  heretofore  never  to  my  knowledge  been 
systematically  described  by  medical  writers. 

Definition.— The  affection  in  question  consists  of  a  fine  tremor,  con- 

J  I  am  under  Rreat  obliRations  to  Dr.  Henry  Hoyiiton  iind  Dr.  Fred.  T.  Kidder,  of  Woodstocit,  Vt., 
and  to  Dr.  Couluid,  of  Cruttleboro,  Vt.,  for  assistiiuco  iu  eecuring  datn  for  my  Listorieg. 


^X,KK  I 


nosis  which  these 
!  clinical  problem 
;)Ws  chorea, 
f  cardiac  disease, 
breath  ;  16  ca.ses 
rdiac  pain.  T\v.) 
•diac  dropsy,  and 
ix>.  The  majority 
ie,  that  the  synip- 
the  compensatoi'v 
lud  obviate  coni- 

g  conclusions : 
•ea — much  larger 
ocardit.'s  lays  the 

s  independent  of 
Bociated  with  it; 
lisease  "  chez  les 
)n." 

:;horea  is  usuallv 
auch  care  should 
s  of  rheumatism. 
:;e,  may  do  much 
to  those  chronic 
the  main  danger. 


CASE     OF 


[TRO.SIS. 


nPllF.VlE   HOSPITAL, 
KAUUATl: 


uliar  hereditary 
knowledge   been 

fine  tremor,  con- 


ler,  of  Woodstock,  Vt., 
iBtories. 


CHOLESTEATOMA 


OF    FLOOR     OF 


THIRD  VENTRICLE  and  of  the  INFUNDIBULUM, 


BY 

WILLIAM    OSLER,     Md 

PROFESSOR  CLIN.     MFn      .  „„,  ' 

•     "*■"•     'NIVERSITY     or     rpvvcv,., 

-^    NHRVO.S    O.SR^SHS  "'"    """'"^- 


[Reprinted  from  The  Journal  ok  Nkkvous  a.h  ^T 

XIV.,  Nove.nber-D::e:Lr,  :8S;.5-'''''  ''""'^'    '°'- 


NEW   YORK; 

1S87. 


I 
) 

J 
I 

M 
C 


u 


s 

'A 
,1 
5 


CASE    OF    CHOLESTEATOMA    OF    FLOOR    oF 

THIRD  VENTRICLE  AND  OF  THE 

INFUNDIBULUiM. 


CLINICAL   SU.\LMARV-._n'   A    r        » 
lad,  had  vi„]c.u  licadnclics  vv'l.ir  I,  l  ^^^     ^^'  ''' 

quent  about  the  eigl,"™th  v  n  T"'"  """'  '"- 
several  attacks  „f  .ra„,sientb  ,  s^  („  i'"'!'  ""\''"- 
when  a  si:,„le„t,  had  trouble  with  I  "i  u'  ',  '"•""'  >"■ 

••">J   would    frequently  faM   alee,      ,:'       "■"*"''" 
graduated    in  ,S;g,  ,„:,,  be,,",    ,n  ette'"';     T   '''>'■     "" 
loss  of  power  and  sen.sa.io.rin   e     a™  ;,„  V''""-'','"''''"' 
tuined  in  an   hour      ^■'...rtk-  \,,     ''".",'"«'  '<=e.  which  re- 
vonming.     Afte    an  ;,    '  l^  ,""'■  ""'""■  >"'=">^^'=l'^  with 
".aniaca?  outbreak     F,    „'  Ir^^tTi.  ''  '""  "  ^'-■' 
ache,  von,iting,  and  great  dro,  1  ",  "X^l  ,",'""  '""'■ 
hours.    Pulse  often  as  low  as  twen^'    .  7'"''' ='=<-'P '"any 
tervalsof  several  days   bLvee.ul "'".T,*'  f "^  !'''"^''     ''- 
was  at  times  incoherent,  .an^ lo     all     e    ?i      "  ""°"'" 
wife  and   faraily.     SLdu  nn  ch  Hil     u    f     °"'""  "'   '"^ 
d.p.opia  ;  one  sb^ht  e;i',ep;rr„  c™  ::  sion"  Tl  ''''\  ""^^ 

"-.-e  about,  thou,\ji;:\-,x''rVclr:ra;-in;:;.! 


) 
1 

) 
{ 

I 

I' 
r 

I 

If 


I  'T 


4  WILLIAM  OSLER. 

vals,  and  the  constant  tendency  to  sleep  persisted.  Gait 
staggering.  In  March,  double  optic  neuritis  was  deter- 
mined by  Dr.  Duller.  In  beginning  of  July,  another 
severe  attack  of  headache  and  vomiting  lasting  three  days, 
followed  by  a  severe  convulsion  and  prolonged  sleep,  from 
which  he  awoke  quite  blind.  From  this  time  rapid  re- 
covery oi  health,  and  for  five  years  was  able,  though  blind, 
to  manage  a  drug  business.  On  June  3d,  1885,  return  of 
attacks  of  headache,  vomiting,  and  prolonged  somnolence. 
Remained  unconscious  until  August  27th,  when  he  awoke 
at  4  A.M.  quite  suddenly.  From  this  time  pain  in  the  head 
was  the  prominent  symptom  ;  no  further  loss  of  conscious- 
ness.    Death  suddenly,  April  25th,  1886. 

Anatomical  Summary. — Cyst  at  base  of  brain  in  posi- 
tion of  optic  chiasm.  Infundibulum  greatly  thickened. 
Small  solid  tumor  in  anterior  and  lower  part  of  third  ven- 
tricle. Dilatation  of  the  lateral  ventricles.  Atrophy  of 
optic  nerves  and  tracts.  Numerous  pearly  bodies  scattered 
in  the  lining  membrane  of  the  cyst,  and  throughout  the 
solid  parts  of  the  tumor. 

The  full  account  of  this  remarkable  case  is  thus  given 
by  Dr.  Duller  of  Montreal,  and  by  the  patient's  brother. 
Dr.  J.  L. 

The  early  history  of  the  case,  as  related  to  me  in  a  letter 
from  the  paticr.t's  brother.  Dr.  J.  L.,  dated  March  22d, 
1880,  is  as  follows:  "  My  brother  began  to  complain  of  his 
eyes  about  the  beginning  of  the  year  1877,  and  all  the  fol- 
lowing summer  he  complained  of  more  or  less  pain  and  un- 
easiness, but  they  did  not  give  out  until  near  the  close  of 
next  winter.  He  was  then  in  his  primary  year  as  a  student 
of  medicine,  and  found  great  difficulty  in  writing  for  his 
examination.  His  visual  troubles  continued  to  increase 
until  about  the  month  of  May,  when  he  went  to  Toronto 
to  consult  an  ophthalmic  surgeon,  who  pronounced  his  con- 
dition retinitis  albuminurica.  This  diagnosis  !  never  ac- 
cepted, for  it  seemed  unreasonable  to  me  that  he  should 
have  such  advanced  symptoms  from  a  constitutional  dis- 
ease without  having  any  of  the  physical  or  other  symp- 
toms of  that  affection. 


<=^Sli  OF  CnOLESTEATOAfA. 

course  of  studies,  n^ev  fs'  ^  n  V''^"  '"  '""^'""^^  '''« 

he  was  first  sen   by  Dr    ^^^^   }"n\''''''  "'^  '''  ^'^^  ^''^e 
His  vision  had  x\2^!\         '"'  '"'   Ciiristmas  time.  ,878 
-^'.du.•tiu.    d  fti      ,r  fll'^P^^^^^'-'^t  he  u-as  able  ' t 
i»  the  sprinc.  o     s '0   ,;.        "'""I^'^'^^'  '^'"^  ^eciical  studies 

whole  ^'nt^    'l^^t  H^unf  l^'^^  "^^"^"^  ^-'^''  ^h 
he  commenced  the  ^^ac     ^of  ^I  "'f  "^  "^  '^   ^'^^^-ee. 
vill^'ge,  and   all  went  we  1    „!       T"^''?'""'"  '-^  ^"""try 
same   year,   when   VZ      t  Lf,"      i"'^  "^^^^   '''  '^- 
headache  and  nausea  wth  occ^^^^^^^^^^^  ^^°"tal 

tnuied  for  about  a  fortn  Ir^^r  °"V''"^'=  '^'''  ^°"- 

tude  and  inability  to  nrle  ^  "'^'"'"'  ^>'  ^^'"^'''^^  '^ssi- 
e'fort  for  hin.  to  tv  st  He  h  J  '''f'""-  '^  '''^'^'^  '''» 
to  Ottawa  for  nud  ol  .d   •  "''^'  "P  ^^''^  '^'"d  to  ^o 

conveyance  that  was  to  Inv:  hi  i^  '•'"""'^ ''"^  "'<= 
"^leep  for  a  short  time  and  ^,,1  "  ""  ""^'^  '"'  '''" 
dchrium,  with  com,  r^r  '"  a  "..lent  attacic  of 

(or  »bouUwe  ,7h  H  .ur?T;°"  l"  "''"=■  "''-"  '-"^d 
a'xl  the  next  dav  he  1,^,  f      /  ^['^^Vrgo  set  hin,  ri(,-ht, 

a.  ™y  house  the  ame  Ih"  fH;  ",  n'  "''"^^  '^^  '"^'^'^ 
that  he  had  been  vomi  i £  hi,  ,7 ''  ''"=  ^^  '"'"'ioned 
his  arrival  here.  T  was  i'  ;  1''""'=™'  ''•■>>'^  before 
The  second  night  af  r  ,  ati  '',1'hf "' "'?  ''"'  *'''5). 
severe,  accompanied  bv,  „tn,  '    .     P'""  ''"came  very 

eighteen  hours  ^  sivera  r'T"^  7™'""^  '""^  ""»"' 
"f  pain  and  vonntinlnow  ah  '  J'!  '"^  ''="'='"'=''  ""••"='<'' 
and  prof„,„,d  sleep      Su'n    ?^^    aggravated  after  a  long 

would  fall  in  frZencv  ;  !h  ;7  r ''''  "'  P''""'  '''■^  P"'- 
even  to  twenty-eigl",  !,nd  '  t "T.  ^f^  "^  '°''>-fi^"''  """ 
"ot  increased.     (Probablv  ^  V        """P-^'ature  was 

would  have  been  no  ced  bv  th'^  '     ^''T'    "=■"!'""'"- 

had  existed  but  he  doSl^^^t^o/ulVilV"''^"^' 

wou!rrt:;rh:':vr,r::t'';:!!,'.-^-^'p'^-'^'^-^ppet.te 


prov.ng.     The   first  treat 
the  first 


m 


SIX  leeches  and 


week  here  while  suffe 


freely  and 
ent   he  got  so 


pparently  be  im- 
ine  time  durinj 


a  blister 


which  crave 


nng  dreadfully.     I  applied 


'-t.the  leeches  had  hardlyta^rUeThf':,:!"" 


in 


s  pulse  began 


r 
) 

1 

I' 
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J 


I' 

8 
A 

3 


, ..     / 


I  ! 


t  ,   (• 


fi 


■'B 


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J 


WILLIAM  OSLER. 


mi 


to  rise,  and   in  less  than   twelve  hours   lie  was   pcrlcctly 
easy. 

"  This  condition  continued  with  very  little  variation  for 
about  three  weeks,  when  the  attacks  became  milder  and 
the  ink  rvals  longer,  but  with  a  steady  decrease  of  wei,i,dit. 
I  applied  blisters  repeatedly,  always  with  marked  benefit. 
I  also  applied  a  scton  at  the  nape  about  the  fourth  week. 
On  one  occasion,  about  the  fourth  week,  on  attempting  to 
stand  up  to  pass  water  he  was  seized  with  a  slight  spasm, 
and  I  think  if  he  had  been  kept  in  the  upright  position  it 
would  have  developed  into  a  convulsion,  but  immediately 
on  his  assuming  the  reclining  position  it  passed  off,  which 
made  me  think  it  was  from  deranged  circulation  on  ac- 
count of  his  having  suddenly  assumed  that  position. 
About  this  time  he  complained  of  a  loss  of  feeling  passing 
all  over  his  body  ;  it  used  to  alarm  him  very  much,  and  he 
used  to  say,  '  I  cannot  feel  anything  but  my  poor  head.' 
It  seemed  to  be  a  numbness  lasting  only  for  a  little  while; 
it  occurred  several  times,  sometimes  all  over  the  body, 
and  sometimes  only  on  one  side.  He  never  suffered  from 
paralysis  of  any  part  or  any  organ  with  the  cxcei)ti()n  of 
his  sight.  The  special  senses  were  all  perfect  the  last 
time  I  saw  him,  about  four  weeks  ago. 

"About  September  28th  he  began  to  show  signs  of  men- 
tal failing,  evidenced  bv  slight  loss  of  memorv,  and  at 
times  it  was  difficult  to  arouse  him  to  perfect  conscious- 
ness ;  he  would  mutter  on  being  shaken,  but  you  could 
not  bring  him  to  himself.  This  would  continue  fcjr  some 
hours,  when  he  would  wake  up  quite  bright.  This  was 
his  condition  at  intervals  for  the  last  week  befoic  I  started 
to  New  York  with  him.  The  pain  during  this  time  was 
not  very  bad,  and  there  was  not  much  vomiting. 

"  He  complained  continuall}'  of  feeling  a  sensation,  in  dif- 
ferent parts  of  his  body  at  different  timeS;  of  the  touch  of 
what  he  called  a  pebble.  He  would  describe  the  size  of  it 
as  that  of  a  pigeon's  <^'g^,  with  a  rough  surface.  Of  course 
he  knew  it  was  only  an  illusion,  that  it  did  not  exist,  but 
he  had  the  sensation,  and  used  to  say  he  had  a  lump  in 
his  brain  and  that  it  was  the  size  and  shape  of  the  i)ebble, 


CASE  OF  Cllor.F.STF.ATOMA. 
btif    the    fact.    „f  his     knowin.r  the    (Ii-,.rno.i«  ^ 

-•[''•''--nmcientrcasonM/hnn      f       L^^^^^ 

and  .<r,vc  rise  to  the  idea  ^""ncct.  the  two 

Perth  train  at  Smill.v  r.„  ,         ,  <'<^^':.<ictl  to  l.iko  the 

we  arrived    t  S,   i ts    ■•   K  i',':    "r '"  , '"-■'  '>'"  '"-''- 

n..l  re„,aine<l  .,  „„ti    >         -rt;  ^^^if,  "J'  f^'-  ^^ 
clay  m«r„i„.r.     He  kcut  nir,   !    it   1       .       "''''  ""  ■^•""'■■ 

o.  su"day.;.hich  w^s'  h  I  ,^  ',t:  d;";"'^'  "'"  •',':" 

was  then  well  et.oni;!,  t„  ,nve  the  ,',1,  ■>  "'">'iy.  He 
C.-.SO,  bnton  SnntlajMtit  ;  :  b™ 'li  "'"■^^  "'  '"'^ 
and  for  the  next   f„,,r  ,,r  five  ,?n  '  ''•""  •'«■""• 

and„.a,,atti,,,e,,nrLM:s'':,{:e;Li;;;;r:,r;:::;:''' 

profouiK   V  so   'i<i  ^r.f,^^,.  1        •        .  '''"^'  ^'•'"  "ever  s(k 

unconscious  until  w^  l\,,  ,       '"'","'''  '""^■^-  "'"  '^'^^ 

Oct    iifh      r  ,'"."'^'''^""~'^'^\vn  home  in  Perth  on 

took  very  Httle  nourishn.ent  .u^  ^1"^,  ^d   t:     b''; 
e.^WUy  pounds-a  perfect  skeleton      Exact  v        f     /      ■ 
from  the  day  we  left   N.mv  V,.  I  ^^-^ctly    a  fortnight 

Sunday  mo  ninl         b^.ht\     n'    ,',;''"'""'■  '"  ^'^"^  '^" 
tins  time   to   ea^'t     sleen^  1^  "'  "V'  '^^'^"'  ^'-^'^ 

weeks  he  .rained  k^h  at'  the  r  f '"  r      ""^^'^''     ^"^"'"  '  '^^'^^ 
until  he  ^ei^heJ^l:----;;^:- 


plac 


c   witnout   treatment   of 


going  about,  he  com 


any  kind.     After  he  be 


took 


iran 


menced  taking  iodide  potass,  up  to 


I 

i 

I 

V 
C 


') 


Sff' 


■.:'■*: 


i 


if 


IV I L  1. 1. 1 M  OSl.EK, 


.,  i      1 


almost  twenty  -grains  twice  daily,  but  iiDf   rcf^iilarly,  and 
aiiotluT  sc'toii  was  put  in  the  neck. 

"  From  this  time  until  Christmas  lit-  remained  to  all  ap- 
pearances  perfectly  well,  without  licadache,  nausea,  or 
vomitiufr.  and  in  the  full  enjoyment  of  all  his  faculties. 
About  Christmas  time  he  paid  me  another  visit  in  I'em- 
broke.  After  he  had  been  here  a  few  days,  the  headache 
and  vomitin^r  returned,  fie  remained  here  a  short  time 
and  then  returned  to  lY-rth,  where  he  remained  until  he 
visited  Montreal." 

I  (Dr.  IJuUer)  saw  V\     L.  for  the  first  time  about  the  end 
of  December,  1S78  ;  he  then  appeared  to  be  in  good  health 
and  cpiite  capable  of  carryintj  on  his  studies  as  a  medical 
student.    I  was  asked  to  examine  his  eyes  in  order  to  ascer- 
tain whether  there  remained  any  evidences  of  the  retinitis 
albuminurica    thoui,Hit   to    have    been    discovered  in   the 
previous  month  of  June,     1  could  find  no  trace  of  disease 
of  either   retina   or  optic   nerves.     Vision    was  normal, 
refraction,  H.  .^'„.     I  also  examined  the  urine  and  found 
neither  casts,  albumin,  nor  sujjjar.     The  specimens  exam- 
ined unrler  the  microscope,  however,  contained  numerous 
crystals  of  triple   phosphates  and  large   numbers  of  small 
octahedral  crystals  of  oxalate  of  lime.    At  that  time,  he  was 
not  suffering  from  headache  or  any  Inconvenience   from 
using  the  eyes  for  close  work  many  hours   daily.     There 
was  nothing   *  ■■  his  manner  or  appearance  to  indicate  a 
defective  st;  u      f  health.     He  next  came  under  my  notice 
on  the  20th    ,'    March,   1880.     His  history  during'  the  in- 
tervening  period  has  been  given  in  detail  in  the  foregoing 
communication  from  his  brother.     He  came   unattended 
to  Montreal.     The  following  day  1  noted  his  condition  as 
follows  : 

The  patient  has  a  somewhat  slow  and  hesitating  manner 
of  speaking  ;  occasionally  he  forgets  words  that  he  should 
be  familiar  with,  walks  slowly,  as  if  feeble  and  languid, 
and  has  a  certain  unsteadiness  of  gait  which  at  times  is 
almost  staggering,  especially  on  getting  up  after  resting 
in  a  recumbent  posture;  at  such  times  he  feels  a  sort  of 
gifldincss.     There  is  no  evidence  of  weakness  in  executing 


r  I SK  OF  CHOI.ES TEA  TOM.  I. 

;«"y''r(Iin.-uv   mnscul.'.r  nrnvements      The   t...  I  n    ^ 

.-.s  a  SUM  heavy  c.-una-nani^.n.  ,•  I v  ,1^;,  '   t!  ''r'""-'" 

wantoraniiiKili,,,,.    ,\i  ilif  ..,„„..;        ,,         '^  H'-' same 
"=  "  ^'  voluntary   ,n„«  nc nts  "■■     ""  '^  ""  ''•='«' 

W.1VS  -..iriics  ll,c   h,.i,l    1        ^.  """■'""!,'.  and  al- 

•  -..cd  a  ih,,     „„',,;;:;:;  ;"'  ,"■•—;    backwa^s. 

Four  days  laic-  (March    c'lhVl  ,"""'  '""  '""  '^""^''■■ 

He  is  also  n,nci,  Z:i^::l:^r^^:i:'^.^^'^'^"^y- 

ants  in  the  hospital  notice  tha      ,.   '  .    ,      "'  •""^^"<'- 

his   tneals,  and'  at  tinte^^acf's'l    W  IJ  I  'T^:.:!' ^- 
•nan  111   IS  walk-  nnri  ^^n^„       .    •      /'""    '"^c  a   di  iinkcii 

wanis u-ite  ;!„;,":  .stai';:  r '",r"""'^' '""^•" '-^■ 

tl-  less.     lIe"attrHn,Lt,,n,cr  "':•',  ""r"  ^"  '"«» 

^^:^:''a^^:h:^';,;:-:7V'"^^^r--'--^^ 
dyna„,o,.cter„ni;;;:::;3?;;:s;  l;t '"'"' "'^^^ 

albnmin,  nor  sn,,a       The     '  '  "'""'""  '"-■'"'<-■>■ «'»''. 

eoveraNc  in  a  y   ,art       ,  ,!■  I  od'  """7^'  "'  "•""'"""  "- 

I'is  complaint;  is  able  to  .rive  a  ,a.  '>e  early  stage  of 

life  ;  close  qn  stion  .  do  ;  ,1  "  "^"'^"l"'""  "'  ^^P"^' 
sible  venereal  origin"  ,,"","■";"""'  "7"  '  "'"- 
thongiitbesttotn  lh,wfr     .    <      ?f'     '    ''■"■    '"'"'ever, 

rapidly  as  the  stomach  would  be-rrr.,'       '"'''T^  '' 
this  was  commenc.rl  n,.  !'.../'''' 'J' ^'-.^^^'' ^'"'"ted  : 


Montreal.     On  March   -Gt 
P.  Howard,  who 


second  da}'  after  1 


n   he  wa.^ 


s  ex- 


gave  me  the  following  notes 


ins  arrival  in 
amiued   by  Dr.  R. 


I 

8 
A 
,\ 
i 


lO 


WILLIAM  OSI.ER. 


■■ 


"Heart    sound,    normal:    pulse,   65;    presents  no  pecu- 
liarities;,  lungs    health}',    but    respiratory   sounds    weak; 
\;j  rig-ht  side  of  chest  flatter  than  left,  and  lower  respiratory 

movementson  this  side  markedly  less  excursive  than  on 
leftside;  shows  an  amioying  restlessness  under  examina- 
tion ;  has  a  papular (?  iodide)  rash  on  body  and  slight 
coryza  ;  body  emits  a  peculiar  musty  odor,  which,  however, 
is  probably  due  to  external  circumstances.  Is  now  taking 
iodide  gr.  xxx.  thrice  dail}-,  preceded  by  a  small  dose  of 
hydrocyanic  acid  a  few  moments  before  the  iodide  is  ad- 
ministered. Still  has  hiccough  and  morning  Inadache." 
The  condition  of  the  eyes  was  not  placed  on  record  \intil 
March  27th,  but  had  not  in  any  way  changed  since  the 
2rst.     It  was  as  follows  : 

Pupils  equal,  in  ordmary  daylight  about  2y<  mm.  wide, 
act  sluggishly  both  to  light  and  ace,  V  =  l  [J  and  Hm  /^-  each. 
The  ophthalmoscope  shows  well-marked  double  optic 
neuritis — choked  discs — not  neuroretinitis,  the  swelling 
being  little  wider  than  tlie  normal  disc  and  quite  steep. 
With  hyperopia  —  J,,  at  macula,  the  surface  of  the 
nerves  is  best  seen  with  +  10.  Veins  dark  and  tortuous, 
but  of  normal  size;  arteries  a  little  smaller  than  normal  ; 
vessels  only  here  and  there  hidden  or  obscured  by  the 
swelling  of  pai)illa  ;  no  hemorrhages,  and  only  a  moderate 
degree  of  white  striation,  and  the  papilla  ai)[KMrs  rather 
reddened  ;  macula  regions  entirely  normal.  There  is  no 
contraction  of  the  visual  fields,  no  defect  in  perception  of 
colors,  and  the  muscular  system  of  th.e  eyes  presents  no 
abnormality. 

lie  remained  in  Montieal  until  Api'il  3d  without  any 
material  change  in  his  contlition  ;  some  days  feeling  a  little 
better  and  others  suffering  more  from  headache  (always 
frontal),  occasionally  vomiting,  was  taking  pot.  iod.  gr,  Ix. 
three  times  daily,  when  he  returned  to  his  home  in  Perth. 
Oct.  2ist.  Came  to  Montreal  again  for  the  day  in  order 
to  have  another  examination  of  the  eyes,  having  now  be- 
come entirely  blind.  Continued  taking  the  iodide  in  about 
the  same  doses  all  summer,  but  for  the  last  three  weeks 
has  omitted   it.     Vision   failed  steadily  from  the  time  lie 


CASE  OF  CHOLESTEATOMA, 


II 


left  Montreal,  but  could  still  see  fairly  well  nh,M,f  .1     1 

headache  and  vomiting  which  lasted  son.c  three  d  s  .nd 
-hn,na  ed  ,n  a  convulsion.  This  was  followed  ^'^^ 
ound  sleep  from  which  he  awoke  cntirelv  blind  wlid; 
has  continued  up  to  the  present  time.  Sine  i.i  ' 
severe  attack  his  general  health  has  steadiK-  n  oJed 
Has  had  no  headache  to  speak  of  since  the  end  of  n  s 7 
-'y  n  ht.le  occasionally  just  on  the  top  of  the  h  ad  'feels 

ance  has  ^^Mx-.<t,\  mi  expression  ;  is  well  nourished    and  in 
He  matter  of  appetite  and  sleep  there   is  nothin-  '        i' 
also  avers  that  sexual  power  is  unimpaired.     The  app    n' 
ance  o    the  ootir  nn,M.r.  •   1  1  A'le.ippc.ii- 

Dorn  a,c  alike  Lxlrcnicly  pale,  scarcely  if  at  all  swollen   -, 
Mo   „,e,n,lar  a,  ,l,e  ,„,,^i,.     The  Veins        to     "„ 
b>  hve.ns  and  arteries  much   diminished  in   si"e      n 
next  seen   by  me  „„  June  .41!,,  ,SS.;carae   ..naeeoun,; 
an  aente  catarrhal  otitis  n.edia  „(  the  left  ear,  whie  i,  s 
cat.sed  h,„,  a  considerable  deftree  of  pain  for  the    a     te, 
ays.  otherwise  his  health  has  been  ler,- good  s  S     i 

."'e,   afford!,  rir""'','"''^'  ""■"'"'"   "1"'--'  -"•"    l-'e 
b  c    »;    W      I  ■■'  ^'''"'""■■''  "'  "Si't  since  the  rlav  he 

became    Wn„l,     I  he  e.ar  tronble  yielded  readilv    to   tie 

br  ir,T;'1"'":H'e':;'""''-''v^?-'«^-"''''>i^ 

trouble  -H,  ■      ,      "■'^"^'''■'""l  Porlectiv  fnmi  the  ear 

SS-     ,:;"""?'    "■""•  -'i°y"'i' K""<i   Health    nntil 
;        •    ^'''-  "''1^'",=;  hvc  years  of  relief  fr,.m  his  trouble- 
«  ben    he  pan,  reappeared,  an.l  up  to  the  C7th  of   \      ust 
be  sulfered  nruch  as  in  the  lirst  illness,  with  seve  e  a  t'^Is 

"'  !«■".  yomitins,  an, ,.  spells  ol  sonmolence     D     ,t 

some  „    these  attacks, he  pulse  was  very  weak -u  d  f 

.ng,  and  u,  one  it  was  thought  that  he  wai  goiu,-  to  .lie      ,d 
v,as  telegraphed  for.     lie  was  more  or  less  tn.co  sci 

:,!!  I!!!':""',;""!-'  '^  ^^''"  "';■"  -'-■  tl--  ""ack  passe<l  off 

poke  was  to  take  up 


on 


the  27tli,  the  first  word  which  h 
tlie  sentence  he  lelt  off  in  June  t! 


seized  with  the  headache.'   On  the 


ree  months  before,  when 
28th  of  August  he  sat 


I 

)' 

1 

I 
r 
1 


1 

s 

,1 

5 


1^ 


A 

,■« 

1 

t 

i 

w 


i>J 


■:i\ 


1 


i> 


12 


n^/LLIAAr  OSLER. 


up  and  took  his  dinner  at  the  table,  and  remained  well, 
with  the  exception  of  slight  attacks  of  pain  until  Nov. 
15th,  when  he  was  seized  with  a  terrible  stabbing,  pierc- 
ing, unendurable  pain  in  the  head  and  his  face  flushed 
crimson.  This  gradually  passed  off,  and  he  was  able  to 
walk  to  the  post-ofifice.  From  this  time  he  was  up  and 
down,  one  day  well  and  several  days  in  pain,  but  there 
was  very  little  vomiting  and  no  disturbance  of  the  pulse. 
He  slept  well  when  not  suffering, 

"  During  the  last  month  the  intervals  of  relief  were  very 
short,  a  day  or   two  at  most,  and   the   attacks   of   pain 
longer,  and  for  the  last   fortnight   the   pain   was  nearly 
constant ;  he  has  to  have  some  person  sitting  beside  him 
to  keep  him  from  falling  asleep  ;  if  he  happened  to  fall 
asleep,  in  a  few  minutes  he  would  wake  up  frantic  with 
the  increased  suffering.     The  Thursday  before  he  died  he 
was   down-stairs   enjoyed  his  meals,  and  he  looked  quite 
well,  and  likely  to  be  so;  he  was  always  so  cheerful  and 
bright  when  free  of  pain  and  suffering.     He  passed  awav 
without  any  struggling  or  any  particular  warning  of  the 
approach  of  his  death.     He  had  peculiar  attacks,  the  last 
three  weeks  before  his  death.     I  was  at  his  bedside  (jne 
morning,  and  he  called  me  in  distress  and  complained  of  a 
strange   feeling  in  his   head.     He  said   his  head  was  all 
drawn  up,  and   that  his   face   was  also  all  drawn  up,  al- 
though   showing    no    indication    or  appearance   of    any 
change  in  expression.     His  hands  and  feet  were  extended 
and  rigid,  but  could   be  flexed   by  force.     He  appeared 
greatly  alarmed  and  distressed,  and  his  appeals  of  distress 
and  alarm  wi^xc  pitiful.     During  the  attack,  which  lasted 
half  an   hour,  his   pulse  never  varied  or  changed  ;  it  was 
perfectly  normal.     The  attack  lasted  about  half  an  hour; 
it  returned  again  several  times  during  the  day.     Another 
expression  he   used,   'xMy  inside   is  all   drawn  up.'     He 
used  the  word  ciraivn  to  describe  the  sensati(jn   in  his  in- 
side, face,  and  head.     He  had  several  attacks  of  this  char- 
acter the  last  two  weeks  before   his  death,  and    it   was 
fearing  an  attack  like  this,  and   feeling  it  comino-  on,  that 
he  called  his   mother  the  night  of   his   death:    he  saiti, 


CASE  OF  CHOLESTEATOMA 

'  I  ^ 

''Mother,  mother,  I  am  ^om^  to  have  onp  nf  f^ 
raise   ,ne  up."     He  then  s^icr^TI"    ,ik-.  f    '?-'"'''^'' 
me  a  glass  of  water  I  •     He  tr  ed   to  <1  -    'j'^"/'?'"^'".^^'  ^et 
back,  his  head  fell  forwarc^::d  l^pa     ^^.l  l^^^l  '^  "- 
moved  ajjain."  F'lsbcu  aw  ay,  and  never 

Dr.  Eraser,  ol  Perth,  Ont    h'i<  nl^n  UM-Jff 
i"g  account  of  the  pat  ent's  V  ;/ i  1 1         ' V'"  '"'''■^■^^■ 
corresponds  ..th  tile  abol^dl;!;!:^^''^'^^'-^'"'^^''^ 

^-ei"^::;^:;;^-:.^:r^dir^:^- 

case  on  several  occasions  with  ]>  B  '  ^  ,  n^'"'^' 
sented  to  ,o  to  Perth  w.th  Drs.  Bul.!>  '  ,  w'^t^JoT"" 
ston  to  make  an  examination  ^        ■^°^"- 

temporo-sphenoidal   lobes       Vo   o.ii      •  ^       ^  ^^^"^ 

but   the    infundibuhu      "is    ^^.^T^^  '\  ''^^^-^• 
u-ith  resistance 'Lt  \t.  ,.  f         ^    thickened,   and   cut 

body  '  '^^'"'  "^  J""^^'^>"  ^^'ith  the  pituitary 

translucent    and  ■,     ".  '  f        ■"'""■  =-"'•  '^"mewhat 

the  plan  a  ;  C,  b        snil  t""",r""  "'"  ""'•'=''«'  '" 
The  mass  occunlll  Zl'^t.'^l  "^'"""^■"■'.■s  in  thickness 


wiiich  can  be 


jpies  the  position  of  the  chi.- 


seen. 


two  millimetres 


Ti 


le  o 


isma,  no  trace  of 


in  diameter 


ptic  nerves  are  atrophied,  only 
■"-  y  in  color,  and  were  at- 


irra 


i 
( 
( 


) 
J 

I 

I 

c 

1 

t 


■I 


■S'-? 


!f' 


1 

1 

3 

r 

i 

!^ 

'J 

'!    i 

•i'l 


14 


WILLIAM  OSLER. 


tachcd  to  the  antcro-cxtcnial  an<rlc\s  of  the  CNStic  tip.iior. 
The  optic  tracts  jiassoff  from  the  postero-exteriial  portion 
and  as  far  as  the  anterior  fibres  of  tiic  crura  are  distinct, 
but  from  this  point  they  are  represented  b}-  a  thin,  pale, 
gray  liands,  scarcely  discernible.  In  front  the  tumor 
presents  a  rounded  smooth  surface,  which  rests  upon  the 
longitudinal  fissure,  and  the  hinder  part  of  the  first 
frontal  convolutions.  Laterally  it  does  not  extend  upon 
the  anterior  perforated  spaces.  Posteriorly  it  reaches 
the  corpora  albicantia,  but  does  not  involve  them.  The 
crura  form  part  of  its  posterior  boundary,  and  they  look 
as  if  slightly  spread  by  it.  The  pia  mater  covers  tiie 
mass,  but  is  not  specially  adherent  or  thickened.  The 
vessels  of  the  circle  are  a  little  displaced,  but  are 
otherwise  normal.  The  nerves  at  the  base  appear 
healthy;  the  left  third  nerve  looks  a  little  translucent  at 
one  spot. 

The  convolution?  ai-e  slightly  flattened,  and  the  vessels 
of  the  pia  not  uni.  v.ally  full.  On  section  the  substatice 
cut  with  firmness.  Centrum  ovale  looks  natural,  puncla 
vasculosa  numerous.  Corpus  callosum  normal.  Latri-al 
ventricles  ai'e  considei-ably  dilated,  and  contain  an  excess 
of  fluid.  The  posterior  cornua  seem  particularly  huge. 
The  veins  along  the  surface  are  full.  Fornix  and  septum 
arc  flattened,  but  can  be  lifted  readily.  Velum  inter-- 
positum  very  vascular,  and  the  vente  Galeni  full.  The 
thii-d  ventricle  pr-esents  the  following  condition:  Pincai 
giand,  with  its  peduncles,  and  the  posterior  commissure 
look  normal.  The  middle  commissui-e  is  large  and  dis- 
tinct. A  firm  mass  occupies  the  anterior  and  lower  part 
of  the  ventricle  between  the  pillai's  of  the  fornix.  It  is 
about  2.5  centimetre?:  ..  '^th  by  1.5  in  breadth.  IJehimi 
it  is  in  contact  with  th"  •  .dami,  and  on  the  right  side 
with  the  smooth  sui,'  je  of  the  caudate  nucleus.  The 
right  pillar  of  the  fornix  is  distinct,  the  left  appears  to  be 
involved,  and  the  mass  is  ol  greater  extent  towartis 
this  side  where  it  is  hrmly  connected  with  the  caudalc 
nucleus.  It  is  solid  in  the  gr-eater  part  of  its  extent,  Ijut 
■centi-ally  there  is  a  cyst  with  clear  fluid.     Whether  this 


rirc  and   tlis- 


C-^SE  OF  CHOLESTEATOMA, 

ori^nnally  communicated  directly  with  the  third  ventricle 
could   not   be   determined,    but   at   the   upper   p.        Z 
wall   ,s   very  thin   and   translucent.     The  i^t  if;,  1." 
contnu.ous  with  the  one  at  the  base  of  the  brlh.    "'^ 
1  he  corpora  striata  and  opt.c  thalan.i  appear  norm-d 
.1  he  tumor  then  occupied  the  anterior  c' tre  u  y     f'L 
hird   ventncle,  partially  involving;   the  left   Dul.ro 
on.x,  but  not  extending  latcrali;  into       e^^if^ 
he  base,  .t  ,nvolvod  the  parts  kn<.wn  as  the  tuber  ci n'^eum 
the   lamu.a   cn.erea,   and    the   infundibuhun,    d^trov  n' 
completely  the  chiasma  and   producing  wa  tint     f'  hf 
optic  nerves  and  tracts.  "^         ^^^ 

The  infu.Klibulum  forms  a  firm  conical  mass  attached 
to  the  lunder  part  of  the  tumor,  and  tapers  to  a  diam  ter 
body       -llu-tres   at   its   insertion    into    the   pit."^^ 

with    the     fhi,.  ;  ^^h^^ther  It  communicated 

with      he     thud    ventricle     was    unfortunately    not    ac 
curately     ^^ed,    probably  it  did  not.     The    li.  in<.    mem" 
braneot    .he  cyst  is  smooth  and   .distenin^^  like  that  of   a 

ventricle,  and    here  and    there   i.r  the   surfacx^^"^^^^^^^ 
yellow  i,n-anules.  i»inau 

At  tl,c  base,  a„ten„r  t„  tl,e  ,l,ickc„c<I  ii,r„„dib„lu„,  ,l,e 

behind  tbej  for,,,  a  l„-,„,  solid  mass  of  a  !,navisl,  color 
.,51  presc„t  a  ,,,„gl,,  .,„,vc„ s„rface.     The  I'^or  i,      i        o 

th,  d  ve„„aclc  has  thicker  wails  in  ,,n,,K,r,i„,  to  „  e  ^     , 
,,d  the  „.snc  l,as  a  grayish  t.-anslncent  aspect.    Thr.n  .   ,' 

the  wall  ,„  i.laees,  pa,ti.-„larl.v  whe.e  thin,  r,  velh.wc   ? 

.s  not.ceable,  no.  „nilor,„,  but  in  sa.all  an,.  ■.     T|,c  t'      e 

o(  the  n,fnnd,bnl„„,  is  soliti,  ..-ay  external,,,  b,      ,        . 

.sh.bnnvn  n,  the  n,.side  and  o„  section  it  cuts  with        ,  uv 

sensation.  '  ■■  "^^> 

Pons  normal.     Fourth  ventricle  and    corpora  quadri 
ireinina  nrespnf  ^^,^\w,,.. _•    ■       -.,,       .  '  iiuanri- 


ina  present  nothin<j- 


lated.     The   posterior  aspect  of  ti 
millimetres  below  t.je  calamus  scri 
remarkable  depression,  as  if  a  ii 


special.     The  iter   not 


much   di- 

e  cord,  about  twelve 

riptorius,  presents  a  very 

'ne  tight  cord   had   been 


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IV.'/JJAM  OSLER, 


r.^.  VI. 


^;- 


VII, 


\+ 


t\ 


'^'\ 


C/ISE  OF  Clfot.F.STFA  rOUA. 

passed   round  in  an    oblique  direction,  extendino- from 'n 
IX'Mit  just   above  the    line  of  emer.rc,  ce  of  ,  . 

roots  of  theHrst  eervical  norve:7,re7,    tl        ZZ 

;^ep,essio„,  and  t^IXt  m':^IZ:^Z!C^ 

cstiform  bodies  are  qnite  distinct  to  its  mnrc^i,  s      Tl 
|3  no  softenin.  no  hypera3n.ia,  no  altJr^C  "^^^^.''Z 
ooks  l.kc  an  anomaly  rather  than  a  pathoIo"nca     ;.    f 

n    h        ^^-  ^  "^r''  "  ^''^'^^'"^'^^  ""'""-  «I<->tch  a?ter  sect  on 

"   the  groove  between  therestiform  bodies  and  th.  ^   . 

nor  column  on  the  right  side.  '  P'''^"' 

msro/ogtca/  examination.~Th^  tumor  consisted  chieflv 

o  ■  (.)  a  matrix  of  densely  interwoven  fine  fibres  wit S 

:T:iTr^Tr-  ^" ^'^^ inf-Kiibuium ^d ; '  • 

wall  of  the  cyst  they  were  more  closelv  <;pf  fi..     •     . 
softer  mass  within  the  third  ventricle      '  " '"  "^' 

(2)  Spmdle  and  branched  cells  which  were  found  in  nil 

emmes  prolonged  into  delieate  filaments  (Fig.  ,  ,,,d 
b).  Some  ,>f  the  branched  forms  were  the  larees  id 
most  beauttful  structures  of  the  kind  which  I  fve  ever 
net  w,th  ,n  e.tl.er  normal  or  p  thological  grow  hi      FiJ 

witn  me  camera.     M-  ny  of  the  processes  were  pr„lo„..ed 
ar  beyond  the  margins  of  the  held.     The  protoplasm  was 
asarule  dehcate,  with  but  few  granules      Here     ,d    l 
were  noted  crious  elongated  no„.,ucLat"d  ee  11     v   h  a' 
hyahne,  homogeneous  stroma  (Fi<r   ,\      I   hnv,.  ^L      ,    j 

br",:  .":„°dr '"^-  "• "  -  °'  ■"«'"''-■  ^^^^ 

bram,  and  have  since  met  with  them  in  several  gliomas  ■ 

narvVJ^dl^'^r"'"  '"T  ""=  "-"-f"™"'-,,  oftherdi- 
nary  spmdle  ce  1.  mnnv  of  »r^;^K  —  :j^    .•     .  .     , 


many  of  which  are  identical  in  for 


m. 


\  m"!""',  x/""'"*"^  '"''  Physiology,  London,  vol.  xv. 
Medical  News,  I'hila.,  1886. 


3 

I 

) 

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I 
C 


I' 

^ 

5 


\\ 


vKvii 


i  1^ 


i8 


WILLIAM  OSLEK, 


(3)  A  beautiful  pavement  epithelium  (Fig.  4)  lined  the 
cyst;  the  cell .  were  not  extieniely  flattened,  and  in  many 
places  were  tilled  with  granules. 

(4)  Pearly  bodies  which  were  attached  on  the  inner  wall 
of  the  cyst,  and  were  also  very  abundant  in  the  thickened 
infundibulum.  These  consisted  of  nests  of  epithelial  cells, 
and  as  many  of  them  were  calcified,  section  with  the  knife 
gave  a  gritty  sensation.  The  concentric  arrangement  was 
well  seen  in  the  smaller  nests,  but  not  in  the  larger  ones, 
which  were  too  deeply  impregnated  with  lime  salts.  The 
epithelial  elements  were  very  numerous  in  the  thickened 
infundibulum,  rmd  all  shapes  and  sizes  occurred  in  teased 
pi'cparations.  Many  were  much  llattened  and  curved; 
others  of  irregular  and  bizarre  form  (Fig.  5).  Some  of 
these  were  of  comparatively  enormous  size  and  very  flat 
(Fig.  6).  It  was  difficult  at  first  to  believe  that  we  were 
dealing  with  epithelial  cells.  It  is  interesting  to  note  that 
there  were  no  cholesterin  crystals.  The  remarkable  in- 
dentation in  the  posterior  aspect  of  the  upper  part  of  the 
cord,  an  outline  of  which  is  given  at  Fig.  7,  showed  in  sec- 
tion a  norma!  white  matter  at  the  base  of  the  groove  with- 
out a  trace  of  induration  or  increase  in  the  fibrous  ele- 
ments. 

Remarks. — Indications  of  brain  trouble  existed  in  this 
case  for  at  least  ten  years,  and  possibly  the  headaches 
which  occurred  when  a  lad  may  have  been  due  to  the 
growth  in  the  third  ventricle  either  beginning  or  assum- 
ing a  more  active  condition.  During  the  year  1S79  and 
the  first  six  months  of  1880,  the  growth  extended  to  the 
base  of  the  brain,  and  produced  at  first  neuritis  and  finally 
atrophy  of  the  optic  nerves.  This  was  due  to  the  gradual 
formation  of  the  cyst  which  occupied  the  position  of  the 
chiasma.  At  this  time,  too,  the  headache  was  most  in- 
tense, the  signs  of  irritation  (convulsions,  para;sthesia, 
vomiting,  staggering  gait)  most  marked.  Recurring  at- 
tacks of  somnolence  occur  with  great  frequency  in  brain 
tumor — particularly  in  syphiloma,  but  I  do  not  think  we 
have  yet  reached  a  satisfactory  explanation  of  their  vari- 
ability.   We  may  reasonably  assume  that  from  July,  1880, 


CASE  OF  CHOLESTEATOMA 

to  June,  1885,  the  brain  accommodated  itself  to  the  in 
creased  pressure,  and  that  during  this  time  the  growth  re-* 
mamed  stationary.     The  return  of  the  symptoms  in  188c 
may  have  been  connected  with  the  devdopmTt  of    h 
hydrocephalus  due  to  pressure  of  the  tumor  on  the  veins 
A  portion  o  the  mass  in  the  third  ventricle  looked  recen  ' 
and  certaM.ly  contained   less  of  the  dense  Hbrillar  connec 
t.ve  tissue  than  in  other  parts,  indicating  possibly  a  more 
recent  formation.     I  thought  at  first  that  the  aLtr^L 
furrow  on  the  upper  portion  of  the  cervical  cord  might  be 
due  to  pressure,  and   in  this  way  might  perhaps  exnhin 
some  of  the  symptoms  of  tingling,  et?.,  of'which  h"cl 
plained  ;  but   the  situation  and    character  of   the  groove 
and  the  absence  of  the  slightest  induration  are  vein  much 
opposed  to  such  a  view.  ^ 

The  tunieur  perl^e  of  Cruveilhier,  or  cholesteatoma  of 
Johannes  MuUer,  ,s  a  very  rare   growth    ,     st   often  r^ie 
with  at  the  base  of  the  brain.     It  'i  in  rea.tyin  e  dot  e 
homa,  and  in  this  instance  probably  began  in  the  cellular 
hning  of  the  third  ventricle,  and   its  extension   in  the  in 
fundibulum.  . 

EXPLANATION    OF    THE    FIGURES. 

Fio.  I,  <,  and  ^.-Spindle  cells  from  the  mass  in  third  ventricle 

F.r..  2.-Lnormot.s  •'  spider  "  cell  from  the  same  situation.     Nos.  7  and  3 

I'll,.  3.— Non-nucleated,  translucent  fibre  cell.  ^" 

Fig.  ^.— Endothelial  lining  of  the  cyst  wall 

F.o.  5.-Irregular  form  of  endothelium  obtained  uy  teasing  a  small  piece  of 

the  central  part  of  infundibulum.  ^ 

Fig.  6.— Enormous  flat  endothelial  scale.     Nos   9  and  3 
Fig.  7.-0utline  of  medulla  and   cord  showing  the  furrow  in  the  posterior 

surface  ;  +  indicates  the  calamus  scriptorius  Posterior 


5 

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X  -KK  II 


««-cee.,  rro™  .H<^,,.^,_^^,.  ,^^^,  ^^^^^^^^  ^^  ^^^^^_^  _^^^ 


HEREDITARY  ANfilO-XEUROTIC  (EDEMA  ■ 

J^Y  WlLiJVM   OSLER,  M.D. 

Till.  INHIIMAIH  ruB  NBRVOI'I  CISEA^a,. 


1"  various  .v,io„s  of  ^dj!:!  r^:^;:;^ ':::  e'^  ''-udden  o^ct 
extent,  and  of  transient  duration       vi  .  ^  ^"^'^  ^""'^^'l  "' 

length  in  text-books  I  ^  di-  ttrr  ''^''''  ^"  "^  »">■ 
very  uncommon,  as  Di..i.ei;d<er'  ";,,  l/o  •  "  '\  '^"'^"''>'  ""^ 
number  of  ca.es  fron.  the  litem;,,  o  ^  O  •  ,^",'"'':'^.'  '""^  ^«"^^^^^'  '-^ 
the  subject  in  ^f>n.f.|.efieJ^^X^U^"''^:  ''''  ^""-'f  -ferrcl  to 
of  Ldmburgh.  has  uritten  on  the  subject  and  GralamM  '' 

good  aceount  of  the  disease.     Ki.hr'  Falcone"  ^.  r  IT  ^"^'"  ^ 

recently  reported  cases  '  '  '^^'•"^'«ff.'  Matas/  have 

andVls  U,i:tSJj:4r:.r ^^^^  ^^  -r  ^-^  generation, 
lowing  report :  ^     '  '"'*'  ^'"^^  ^P^^'-'^l  "^^ercst  to  the  fol- 

Briefly  summarized,  the  affection  Jn  fi.«  ^     m 
has  the  following  chumcter'sUcs  "^ ^  ^'  '"^"'^  ^  '"^^"  ^'^^'^^ 

1.  The  occurrence  of  In        swt.i];n,«.  ;„ 
iace,  ha„*,  „„„,,  ,„,,  go„i.a,s  .l^/:  JZ^-"^  •"'  "°  ""^^^ 

po«ib.yi„  «„  ae„,K  ,.,„.ed  ...  ^ ^ud^n  i' ,^„  ^ »™  ■""»-, 

1.  Associated   with    the  fpHpm.,    fU^       •      i  ./'^"""fw. 

i~.o..inal  disturbance:    „  i.-^l:,  *"°  "  "T  '-"""Wy  Sa„r„. 
3.  A  .,™,g.v  „„.ked  lier^ta  ;  d^5i:;''^"'J™"''T''™■ 
.ffectedmembe,.oi•thcfa,,,i,yi„«;ei,^^S^„°:  "■"  ''""'"'^   '""'°» 

Anieniberof  thf'familv  Mro    pt  j^ 

to  the  Infinnarv  ibr  N    iCiifea^rl^rT'^V;/^^^^^  "as  admitted 
lowing  notes  were  tak.n  b^Dr  Burr  'fhe^  ''"^'','^'.^.^^"-  ""^  the  fol- 

Medium  sized,  well-noukheAnnw.      '^''•''''■''''''''^"  ^ 
Bvn>pton,s.     Has'  been  ma       d  two  ^ea  «''  nTu     '''''\  neurasthenic 

-  has  hee.:;ul^t\^ -K--„  -  -§,;;^.he  .^^ 

\  Dil";?''  ";.'■  .^'"'"-""P'""  Nouro,o„c«l  Socletr. 
•  IJiukelaker  :  Leber  aiiitno  ii'.i„n.      x  „ 

'  "";'"  ■■  *''»*^"''  i"  Lon Mo.,.  llcorU,  l)„c   1887  '  '''""""'"'  P""'""™",  I880, 

FalcuDo  :  Oaz,.Ht«  dogli  Ospltali,  Feb.  24,  W8f,  ' 

Matas :  K    .  Orleaiie  Medical  Journal  Oct  1887  '  ^"■"'''°«'  1^°^  ^3  Matas. 


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^1 

2         OSLER,    HKKEDITARV    ANG  10- NKU  ROTIC    (Kl)KMA. 

hands  or  fingers,  knee  cap».  elbow.-!,  buttoi-ka,  urni  or  lliigh  in  fleshy 
parts,  fiice,  or  more  ofU'ii  I  lie  lips  alone.  The  Hiifiers  luive  been  so 
swollen  that  it  was  inipo.-^sihle  to  move  them,  and  onee  the  rin<,'-fin<;er 
was  so  greatlv  enlarged  that  the  ring  had  to  he  filed  oH'  to  prevent  gan- 
grene. The  nderlip  has  been  swollen  to  such  a  degree  that  the  mouth 
could  not  be  opened,  and  milk  had  to  be  poured  in  from  above.  A 
slight  redness  and  itehing  of  the  pail  is  first  notieed,  or  a  sensation  of 
heat;  the  redne.ss  is  not  always  juesent.  The  effusion  may  take  jilaee 
with  great  raj)idity.  She  often  ha.s  red  spots  on  various  parts  of  the 
skin,  or  irregular  lines  of  redniss  witiiout  any  swelling.  The  duration 
varies  from  one  to  four  days.  Tiiere  is  not  imu'h  iW'hing,  partieularly 
when  the  swelling  is  great,  but  a  sense  of  distention  an.l  stiffness.  When 
fully  out  it  does  not  pit,  but  does  so  when  going  down.  The  attacks 
may  come  on  when  she  is  feeling  (piite  well  or  then^  may  be  slight  indis- 
po.^ition.  In  all  the  severer  ones  there  is  abdomimil  pain,  described  a.s 
colic,  with  nausea,  and  often  vondting.  There  is  sometimes  headache; 
no  fever.  The  attacks  have  no  relation  to  the  menstrual  flow.  She  rarely 
l)asses  two  weeks  w  ithout  an  attack.  She  does  not  think  that  food  has 
anv  influence  on  her  ease.  She  remained  in  the  hospital  three  weeks, 
during  wliich  time  there  was  no  severe  attack,  but  she  had  numeroii.>- 
wheal-like  eruptions  on  the  chest  and  sides  of  the  thighs,  with  very  slight 
swelling,  aiul  the  day  before  she  left  there  was  a  large  si)ot  of  local 
(wdenia  on  the  inner  aspect  of  the  left  thigh.  Dr.  Morton  dilated  a 
very  narrow  cervi.K,  and  she  went  home  much  improved.  She  had  not 
passed  three  weeks  without  a  severe  attack  for  a  long  time.  I  saw  her 
again  on  -lanuary  10th.  She  had  liMiror  five  bad  attacks  on  the  hands, 
feet,  and  thighs,  since  leaving  the  hospital. 

From  'Slv.  T.,  my  i)atient'8  grandfather,  a  venerable  old  patriarch  of 
ninety-two,  with  unimi)aired  vigor  of  mind  and  body,  I  was  able  to  obtain 
a  tolerably  clear  history  of  the  affection  as  it  has  existed  in  his  family. 

First  Gi:xeration. — The  disease  first  appeared  in  his  mother,  Mtr- 
(/(ini  A.,  b.  1762,  d.  1834.  He  thiid^s  it  began  with  her,  and  feels  sure 
that  had  it  been  in  her  father's  or  mother's  family  she  would  have 
known  of  the  fact  and  mentioned  it.  She  was  twice  married  and  hud 
two  children  by  the  first  husband,  and  three  by  the  second.  She  had 
the  attacks  from  an  early  age  in  the  hands,  feet,  face,  and  neck.  Ho 
had  fre(piently  seen  her  in  them,  and  on  one  occasion  she  nearly  dird 
in  an  attack  of  shortness  of  breath.  She  had  colic  with  them.  After 
the  age  of  forty-five  or  fifty  years  she  was  not  so  much  troubled,  hut 
her  constitution  was  nnich  weakened  by  the  strong  medicines  which  she 
had  taken.  She  had  evidently,  from  the  account,  been  badly  salivated. 
She  sought  advice  "verywhere,  but  in  vain,  and,  according  to  my  patient's 
mother,  was  brouL.it  to  Philadeljjhia,  to  the  Pennsylvania  Hospital,  to 
see  Dr.  Rush  or  Dr.  Physick.     She  died  at  the  age  of  seventy-two. 

Skconu  Generation. — Of  the  children,  all  boys,  four  grew  .p; 
Samuel,  Stacy,  John  M.,  and  Allan. 

Samuel  was  not  affected,  but  his  children  have  the  attacks,  and  one  of 
them.  John,  died  of  the  disease  in  Salem,  ]\[ass.  Particulars  could  not 
be  obtained. 

StacAj  was  never  attacked. 

John  M.  suffered  i'v  .ra  his  youth,  and  had  frequent  attacks  on  the 


(K 1)  K  M  A  . 


attacks  on  the 


hill 


OSLER,    HEREDITARY    A  NO  ,0-N  E  U  ROTIC    CEDEMA. 
;!>;  an,l  privates.     Ho  h,.,  ,;,„r  duUhen  1 
''III,   aj.(.,l    iiiiiofy-two  V 


iviiiK,  of  wlioiii 


A//< 


"Illy  one  Ih 


Itii^.andHtillahro  to  wAlk  fi 


fllCll 

an  a 

tice.  at  thf  ivn<  „f  ,,i,ri|f 


t'iWM,  a  hale,    vi 


,">r()iis  man,    with   [XMfccf 


""•^.  ...u  m,n  11,  ,0  to  v.'iilk  five  or  six  .nil  .s  i  ,|,,v        r   .'    ', 

chih  .     K(Mno.Ml.ors  that  tl...  ..ff,.„L.:  i     .  ..  '''>•.    "^  ^^"•■^  ''i-'»l'l 


'It  the  attack.s  hcoaii  while  I 


hv 


valw  of  a  iiiDiiti 


•'liii  or   iiiiiotee 


f 


rei|iieiit. 


Tl 


ii  or   six  weeks.     A  few 


Tl 


ley  liave  recurred 


10  was  an  apjiren"- 


tio  last  attack  was  two  week 


the  first  symptom,  and  in  1 


years  n^o  they   i)eeame  I 


ks  a''o. 


Tl 


lit  int<'r 


less 


commonly  affected,  less  oflen  tl 


iS:;i.  ;".ir;;.:  ";'!•;■■;" '""iirva.., ;;;.., 


Itch  in-    precedes    the    onset.     The    (ed 


1*!  trunk,  and  never  the  fa 


"',-\velini;r  is  nsiially 
Ik'  parts 


CO. 


f,'.r>  in  an  attack  are ^. so  thick  and  slilf  tl 


etna  conies  on  rapi( 


sometimes 
'y,  and  th(! 


La,  tiu.  coiaTiVf;;;;  h^cz^  CZ:''!^  ^'"^;^  i^  impossiide  t;;  n.;;; 

are  felt  in  the  al.(l.,me.    m       »  '    '  • "  ^'"t"'^' <>»y-     Colicky  pains 

usually  with  reliiV  'EVc  .ndh.:;  ."""T  'Y  ^'"""""'^  ''"''"  "^ 
l.il.^  luul  to  come  np  hofW^l^t'  i^^i!  ^  :^:'!;'-^ ''-^j--<'  i^  'the; 
poes  down  before  the  sickness     Vom7  in     i«  „  f  '  •'"^'"'"^'  ^^^'uerallv 

attack.  The  entire  duratio.Hs  KT!^  >  t h  ee  da;::''''^!''''"^^  "V" 
headache,  and  very  exceptionally  diarrh.ea  W,  v  l.  .  i  V  '"■''''■  '"'•' 
to  cold,  and  imliscretion  in  diet:  we  e  .V  i  ^  ''  "'"''''  '^^•^'l-^uro 
thiuks  determine  the  attacks  1  ..he  ?s  ""/v^  e.rcu.nstanees  which  he 
apnarent  caii.se.  '     ^  ""'^  "''  '^^^^"  '-'""'^'  «•"  without  any 

second  wife,  are  affected.  '"""^''  '""'  '''^  <i'iUf?liters  by  the 

about  the  ajre  of  twenty  and  b-.r!   ,"  .  i      '     '^^    "'^^  ^f-''"'"     t, 

ap.'d  sixty,  of  Bri..ht4?li  ei  e      Of 'hT      ""'''  \'n\  """'•'^•■'-     "^'  <»'«•» 
ception  are  affected  ^  '"'  "'""  ^■'"'^^'•^"  '^'^  ^vith  one  ex- 

fbr  the  colic  ^  «i"euac(l  hei  and  given  hypodermatics  of  morphia 

.e£""i^u,:td^:i.;;^ert^:t^  "i?  'i"-^^  --^  ^^^^■ 

body.     Has  to  be  ve  y  carS  i     1  e    .  i  . t  T"  '  ^''1  "^■^^"   "»  ^he 

vegetables.  ^  ^  '"  ''''  ''''^'  ^"""'^t  eat  apples  and  certain 

«.Ilos  in,  f^ts  abo..t  tll^iS;  in  U  dsZ-lt'^'  ^"  ^"^  ''''^''  '^  ^'^ 
and  o^'X't^s  v^vXfsS.^^"'  '^"^'^  «i' --»P«  i"  the  stomach 

t.. '  vSc^tSnrn.;;:;:t::l-;^       - «-  ^-^«  o'^.  -d 

i'a.l  three  children  one  at  ivp,,    .  .      '' .'''^  ""'  '"'"''•'^'^l-     -^''e 

attack);    a  third  at  ebrl.th  Z,      '     .;;^'    i  as  recently  had   her  H..t 


month,  livi 


-s  prematurely  bro^^;  :„"^;'    l^'I^S.,^"  '^-'^  ''f--"  H.c  labor 
at  0  A.M.,  evidentl"  '  '  -         ^"uip'aint.     S|ie  died  m  ..t.  .iff„„i. 

Dyke,  of  New  B 


y  a  sudden  (edema  of  the  I 


Dr.  Williamson 


'unswick,  was  called,  and  before  her  rcnil 
'imved,  she  was  dead. 


ilmira,  who  has  never  had 


'■^he  died  in  an  attack 

yynx.     The  late  J)r.  Van 

ar  physician. 


4.  Mar;/  has  alwavs  had  the 
this  winter 


it. 


5.  Julia,  "who  always  has  swollen 


cramps  but"  swelled  "fbr  the  first  time 


ever  since  she  was  a  small  child. 


r 
) 
J 
I 

V 
0 


I' 

8 
3 


■I 


ll: 


4         OSLER,    HEREDITARY    A  N  GI  O- N  EUROTIC    (EDEMA. 

6.  Kate  has  it,  but  "swells"  less  frequently  than  the  others. 

7.  Edwin  within  the  past  few  years  has  had  bad  spells  of  both  cramps 
and  swelling. 

8.  Maggie  (case  of  ]\Irs.  H.  who  came  to  Infirmary). 

9.  George  has  always  had  bad  spells  of  the  cramps,  and  last  summer 
"  swelled  "  for  the  first  time. 

The  mother  writes  that  none  of  her  children  has  ever  had  chilblains, 
but  all  suffer  with  cold  feet. 

Fifth  Geneuatiox. — Lizzie,  daughter  of  Hamilton,  has  had  some 
very  bad  attacks.  She  was  married  in  February,  1887,  and  has  had  six 
bad  spells  since.     Once  her  face  "  swelled  out  of  all  shape." 

A  son  of  H.,  also  has  bad  attacks. 

A  daughter  of  Kebecca,  now  seventeen  years  of  age,  "  swelled  "  for 
the  first  time  this  winter. 

Genealogical  Table  showing  Angio-neurotic  CEdema  in  the 

Family  of  T. 


I. 


Margaret} 
1).  17t)2, 
(1.  1834. 


Samuel, 


Stacy, 


III. 

3  cliildren  all 
afiectod;  1 
(.Tolin)died 
of  it. 


Allan, 
10  cliildren, 
3  allected. 


George, 


John  M. 


Emma, 
single. 

Sallir, 
nuirriod  ; 
no  cliildn;!!. 

4  children ;  1 
-  (Angoy)  iil- 
(    fectcd. 


IV.. 

One  girl 
atl'ected. 

Hamilton, 


Rebecca, 
died  of  it. 


Ahnini,' 

Mar  I/, 

Julia, 

Katie, 

Edward, 

Maggie, 

George. 


(  Thomas, 
\  Lizzie. 

2  children, 
aged  17  and 
11,  one  of 
whom  hfvs 
recently  iiad 
her  first  at- 
tack. 


J 


The  general  characters  of  the  oedema  may  be  gathered  from  tlio 
description  given  of  the  cases  of  Mrs.  II.  and  her  grandfather.  A 
review  of  the  literature  shows  that  all  of  the  cases  in  this  respect  are 


1  Those  in  italics  have  suflcrod  witli  the  discMe. 


liUEMA. 


'swelled"  for 


EMA  IN  THE 


OSLER,   HKEEDITAKT    ANaio-NEUEOTIC   OiDEMA.        5 
very  si,„il„P.    I„  „„e,  the  swelling  i,  „,„re  c„„,ta„t  Id  one  leclitv  „ 

oae„  p.»„e  .e  „„«,  J.  ^^  :::^^  r'xrrj'r 

A  special  interest  pertains  to  the  occurrence  of  cedema  about  tl,e 
throat  and  larynx,  as  sudden  and  extronie  involvement  o/thT 
.nay  prove  fatal.  In  Case  I.  of  Quincke'  and  Di  klL  't  "  S 
a  man  aged  twenty-two,  had  repeated  attacks  of  suffocation  len  nth 
cyanosis,  :n  assocuuion  with  local  o^denua  about  the  joints  l.^",  J 
pains.     The  mucous  membrane  of  the  I.,,.vn.-  colicky 

A    1  .  '  ^^"  ''"'"'>' there  was  oedema  of  the  II viilft 

Laudon  had  in  ]„s  own  case  swelling  of  the  pharynx.  Cuntz^  desc  i  es 
a  case  in  which  the  patient  awoke  one  night  with  great  dyspna'a  aTd  a 
sense  of  suffocation,  which  passed  off  in  a  few  houis 

In  one  of  Riehl's  cases  the  patient  had  three  attacks  of  angina  with 
<1  ffio  Ity  of  swallowing,  and  great  breathlessness.     In  his  second  ca  e 
also,  the  man  is  said  to  have  had  inflammation  of  the  vocal  coTvlS 
had  produced  symptoms  of  suffocation.  ' 

In  several  cf  the  cases  there  was  a  remarkable   regularitv  in  the 

^:zz  \:'^r''''  T''-'.'^' '''  seventi^:;i:ui 

The  hereditary  aspect  of  the  disease,  which  is  so  well  illustrated  in 
e  family  which  I  liave  studied,  has  been  noticed  by  thre    o    '  n.rs 
In  Quincke  s«  first  case  the  man  had  two  children,  one  of  whom  Vl     1 
ged  one  year,  had  had,  from  the  age  of  three  months,  attacl^'      ]     ",' 
c^ema,^often  precede  by  a  red  and  marbled  conditi.i  of  1  sklrol 

^^:^^^:^i^.  ^  '"^'^  «^^^  ---^'  '-'  "^  -  ^vho  suffered 

In  Falcone's  case,' a  lad  of  seven  years,  with  well-m.rked  attacks  the 

li^t:;  been  aU'ected.  but  the  grandfather  had  been  aS t 

most  distressmj 


usually  requiring  morphia  for  its  relief.     It 

'  lioc.  cit. 

'  I>-'ut8uhe  niB'!.  WochBiisohrift,  1880,  N,)   17 

■>  UiKlon  :  Berliner  kli„,  Wocl.oiiaolirift,  1880 

°  Loc.  cit.  7  T  •> 

'  Ijdc.  cit. 


symptom, 
is  interesting  to  note  that 


•  Loc.  cit. 


5  Archiider  llcilltuinlc 
'  Loc.  cit. 


B.I.  XV. 


( 

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1} 


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3 

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3 


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1        J; 

' 

1                                             * 

' 

i 

J 

OSLER,    HEREDITARY    ANGIO-NEU  ROTIC     (EDEMA. 


there  is  a  disease  in  children  characterized  by  painful  cedomatous  swell- 
ings about  the  joints,  a  purpuric  or  urticarial  eruption,  and  most  intense 
colic.  There  may  be  hemorrhage  from  the  bowels,  but  the  skin  affection 
and  the  colic  are  the  prominent  features.  The  attacks  may  be  repeated 
at  intervi.ls  for  many  months.  Gouty'  lias  given  the  only  full  account 
of  t!ie  disease.  Henoch'-  has  also  reported  four  cases.  I  have  recently 
had  an  opportunity  of  seeing  a  typical  ease  of  the  kind  with  Dr.  Dunton, 
of  Germantown.  A  boy  aged  six,  has  had,  during  the  past  ten  weeks, 
three  attacks,  each  one  extending  over  many  days,  of  purpura,  with 
urticuria,  swellings  about  the  ankles,  and  intolerable  colic.  He  has  also 
passed  blood  in  the  stools,  and  the  urine  contains  blood,  albumen,  and 
tube  casts. 

So  far  as  I  can  gather,  none  of  the  members  of  the  T.  family  has 
had  purpura,  nor  have  there  been  painful  swelling  of  the  joints.  Some 
of  them  have  had  urticaria,  and  Mrs.  H.,  whi'e  in  the  Infirmary,  had 
very  characteristic  wheals  on  the  chest  and  thighs. 

The  colic  is,  in  all  probability,  due  to  oedema  of  local  regions  of  the 
intestinal  wall  interfering  with  the  regular  and  uniform  progress  of 
peristalsis.  The  colic  of  horses  is,  in  most  cases,  the  result  of  hemor- 
rhagic o?dema — infarction — of  a  limited  portion  of  the  intestine,  due  to 
embolism  in  association  with  the  common  verminous  aneurisms  of  tlu' 
me.«enteric  arteries. 

Quincke  has  termed  this  condition  cmgio-neurotic  oedema,  and  regards 
it  as  a  vasomotor  neurosis,  under  the  influence  of  which  the  permeability 
of  the  vessels  is  suddenly  increased.  That  it  has  close  relationship  with 
urticaria,  a  skin  disease  of  unquestioned  neurotic  origin,  is  shown  by  the 
frequency  with  which  in  the  reported  cases  we  find  mention  of  the  affec- 
tion preceding  or  accompanying  the  local  a?dema.  The  condition  re- 
sembles in  some  points  urticaria  tuberosa,  and  Juler,^  in  a  very  abk' 
article,  describes  a  case  of  u.  porcellana  which  evidently  belongs  to  the 
affection  under  discussion.  In  our  present  state  of  ignorance  of  the 
factoi-s  which  regulate  transudation,  it  seems  useless  to  enter  upon  a 
theoretical  discussion  on  the  subject  of  nervous  oedema,  and  we  may 
conclude  with  Cohnheim,*  "that  we  have  to  do  here  with  clinical  facts 
and  observations  which  urgently  call  for  scientific  solution,  and  that 
we  possess  at  present  but  extremely  scanty  material  for  an  adequate 
explanation  regarding  neurotic  oedema." 


1  Gftzotto  Ilebrtomiuliiire,  Win. 

-  lU-iioch  ;  Jii-riiiuir  kiln.  Wudionsflirift,  1871. 

'•>  Cinoitiniiti  Liuifot  and  Observer,  1878. 

♦  Allgeinuiiu'  I'lithuloKit',  Hil.  1,  p.  500. 


EDEMA. 

lomatous  swell- 
id  most  intense 
B  skin  affection 
ay  be  repeated 
ly  full  account 
.  have  recently 
th  Dr.  Dunton, 
past  ten  weeks, 
purpura,  witli 
!.  He  has  also 
,  albumen,  and 

T.  family  has 
3  joints.  Some 
Infirmary,  had 

regions  of  the 
rm  progress  of 
isult  of  hemor- 
ntestine,  due  to 
leurisms  of  thr 


ui,  and  regards 
le  permeability 
lationsbip  with 
s  shown  by  the 
on  of  the  afl'ec- 
le  condition  re- 
in a  very  able 
belongs  to  tlu; 
norance  of  the 
•  enter  upon  a 
\,  and  we  may 
\i  clinical  fads 
ition,  and  tliut 
)r  an  adequate 


t: 
i 

9 

)I 

y 

i 

I 

•I 

I 


u 

s 

A 
i 


W 


I  II 
■  II 


I    / 


.« 


Lxxx'iv 


I    ' 


The  Medic 


VOLUME  III. 

NUMHEK  4.  A  1 

THE  DIAGNJ 

'^y     WILLIAM     O.'i 

l-ROFESSOR  („.■  CLINICAL  MFlj 

The  MEDICAL  Standard  (March)  has  ' 
tonally  outlined  the  present  subject,  and  in 

necfon  with  this  editorial  discussion  the  fol 
.ns-bncf  notes  may  prove  of  interest.     I„, 
"nset  of  ,he  di.sease  the  difdcultv  of  dia.r 
"'a.v  be  very  great,  even  ^vith  u•ell-de^•el 
nausea  and    backache.     Mistakes   arise    in 
niajonty  of  instances   from   the  occurrencl 
certannnitial  rashes  which    in  so„,e  epide. 
are  very  common.     In  the  Montreal  epidem 
_>874-,-6.  they  were  more  frequently  met   ^ 
■hanm  the  recent  outbreak  of  iSs/.e      Svc 
ham  refers  to    them   in   the   following   wo, 
The  aforesaid  smailpo.K  breaks  out  someti 
N^rthefashion  of  erysipelas;  somet,:: 
jeasles     From  these   they   are   difficult  tc 

«,.j..shed,  even  by  the  practiced    Zs 

Hed  t  at  he  goes  by  e.xternal  a  pJa;: 

W-      f  hey  have   been  well  studied  by  3 

t-anphys,,  ,ans.     Bartholow  observed  then^ 

>™nnt,.    The    fullest    description    in    E 

iJ£li'£ll...in  an   uvt'n-],^   i.,i,,„u  , 


d  aqi  3.1L'  Asqj  ajsqAv  sjKipD  oiui  sppno  puy 

.oqB  puuojSuazojj  puB  soi  'a\ous  avfl  Xq  juiBiis 

I  ui  ppn  suuoS  astjastp  pui?  sasTjS  uiiav  uapiq ' 

U3.UI13-J1H  punoa.Sjapun   3\\\^     'uosiod   pooiq 

j  'pjoj  itsij  o;  3np  3q  sojoj  s.uau  jo  ssoj  aqj 

jqiaq.tt  'pay.-iAi;  oq  oj  si  anssi  \v.-\v}  v.  }\  luamiBsaj 

AisKwp  'jduioad  'uiuyaD  puBiuap  asaqx     ''^liotid 

;o  iSuijsissj  pai^  uoipunj  jo  sso]  SuiXuudiuoDOB 

|;i  mi.w  sissjBd  Ti  JO  sfsaq^odXq  aqj  uo  aiqBOjid 


9S 

small  pox  departmei*'  '^^'■'■ 
pital'  did  death  occu 
most  careful  inspec 
papules.  In  three  i 
place  on  the  fourth  i 
was  beginning  to  api 
prevailing,  there  is  r 
nosing  this  so-called 
lated  cases  it  may  t 
rash  do  not  develop 

The  prodromata  (A. 
acteristic  and  of  gre 
early  stage.     I  saw 
diagnosis     in     pur| 
year-old  child  was  t  ™  "^"^ 

,  ,  FOR   DIS- 

great  pams  in  the  I 
second  or  third  day 
skin.     The    nervouj^j^j^   j 
there  was  retractior,       , 
the  limbs.     The  cur    ''*^"' 
more  abundair  anc^'  ^"*^ 
oneof  cerebro-s,;'n;       He 
Jr  and 
years 
1   of  a 
le  has 

The  term  "WintJan  to 
relic  of  the  time  Ivania 
"Black  Measles,"  j  only 
the-Back"  and  sir, 
invented;  terms  as 
a«  are  the  theprjes 


ently, 
ilso  to 


i^s:  Is 

ins  of 

er  his 

The 

JO  paiuHduioDDB  aq  pinoA\  aaqif  legs 

ft  ui  jnoDO  Abui   -j  „09  jo  v       . 
. "  arnes 

0;BUJII:>    3[qBUBA    A[31U3J1X3    s'p 
U:   SB  J3;UI.\\  UI  3SB3Stp  3qj  04  .)■     "*"^ 
qDB3'siiqBq  A|UB3]Dun  pire  p3si   feels 
'sSuipiinojjns  Ajjiq     'saouaniilone, 

TjSUB  i<IUBSS303U  pjUO-W    SB    q''aImO- 

X[uo  aqj,     -jsjuhtt  puB  •'^^^"'""'(lancls 

-r^  -,r<r»TtT    ,rt?     i-iAAciit>    (W  3ABU  S7 


I); 
r 


s 
n 
e 
h 
;e 
i< 


t; 
b 

e 
ii 

0 

s 
)i 
a 

:r 

tl 

a 

h. 
•a 
t( 

e 


.  :i 


The 


.DM'ME  III. 
Nl/MBEK  4. 


Medical  Standard. 


I 


APRIL,    I8S8. 

THE  DIAGNOSIS  OF  SMALL  Pox, 


^CmCAOO: 
<■  P.  ENGKMIAUD&CO. 


the  MEDrcA.  Standard  (March,  has  edi- 
onally  outlmed  the  present  subject,  and    „. 
U,n  vvuh  this  editorial  discussio;,,',: 
.^'  br,ef  notes  „,ay  pn.ve  of  interest.     ,,      L 

^to^thed,seasethedi,Hcu,tyofdia^:.' 
m   be  \erv    ,^.reat.   even   witi,    vvell-developed 
Usea  and    backache.     Mistakes    arise   ^the 
'-'"'.nty  of  instances    from   the  oc-urrence  o 
;rta.n  ,n,t,a,  rashes  which    in   so„,e  ep  cic   ,i.^ 
-ery-o„.n,on.     m  the  Montreal  epide,; 
n~,~0  they  were  more   fre<,t,ently  n.et    with 

P     'c  ers  to    them  m  the   followin^.  words=. 
:u^aforesa.dsmallpoxLreakso„timet^    ; 

^^^ef..h,on  of  erys,pelas;  sometimes    ^ 
me.Meb.    trom  these   ihpv   .,r„    ^tc     , 
*„,ui.shed  evenbvt.      '"^^  ^' ^^'"'^  ^^^  >^e 

^VK^d  that  hr,oes  Iv    "T    T'  '"•^■"'■'■''^"- 
I  .,    ,,,,         '^  '^"^-^  '^y  external  appearance 

1^        I  hey  have   been  well  studied  by  Ger 

Physicans.     Bartholow  observed  theni  I 

""-t..    The    fullest    description    in    En " 

.S?3    ^d^:^  t"/"'^'''^  ^^•'"''h  appeared  m 
aS,  f'   '"'''"''   ""  observations  nmde  in 

Montreal  General  Hospital,  and  in  an  Irticle 
'r.  Seymour  Sharkey  <  '-"title 

""i"t.''?:fr""'^"™^'"^he'nitial 
nrst.     ihe    hsmorrhamV    uh.Vh 

'recautions  to    hp    t=i.  neces- 

>, ,    ,  '°   "^^   taken  even  before  rhp 

-crashes  n'theeruralo-^;'^''"'^"^ 
f^nnff  from  thJT     f       ''■""^'■>'  ^"^ngles, 

f--softh?d;seas^™"°^^^"''--^e 
^™n^J.-The  erythematous  rash,  which  may 

r"'  ^^'"'^"''■^n,  Society,  Vol    r   „ 


"ospiial  Reports,  ,882. 


be    diffuse    and    s.-,,-i.,,-       r 
^'--uralandte^'::/"^'".  •''•'-'•-'  to 

'•a.se  it  is  usuilK  '■'■■''^'""■''  '"   ^^•'i''''h 

havehearr;:;t,r;;::;::;:f'^--'^'-  ^ 

this  varietv  of  r-,sh  '■'"'''   '"  ^^'^''^f' 

^Ha.nosis:ft;:^;:::r'':«,-^b-.iedtoth.. 

'"'H'd    .scarlet    fev./'       ,  '''''^e^  "f  com- 

'- the  older  wn\:""'    ^'"f"P'«.  described 
ture.  ""'''^^•^^'■'■'■ITobablyof  thisna- 

Third.-^-Thcmaculou.s^rmcaslv   ,-,sh    i 
■'^"'■ommon.     [    i,,,,.,-.    ^  ,'    '  "^  ""' 

■■""Pleofit      In      ,      ."■"   ""'>■   ""'^.U-odex- 
-h  papules       ,  ■-•'■"»-■-  a  m.ottled  ra.sh. 

>-n,ln'i^;,'    ',:::'''---•     If-'Klone 

^vitb  distinct  snvd    I       '"''"'^ '■"''''"'""^    ra.sh, 

"-.'^-'^"-i-ia;r;:tt^ri:r 

'^'••^^  to  his  home      n  ■"'"'de.  and  .sent 

u-ns    .,k  .      ''"^^  "'y  '''''■'^'^"^e  a  child 

was    also   admitted  with    nie-islp;.      v./ 
these  cases  took  smallp  .      ,   [.  ,    ^'''''"-  "^ 
J  saw  at  the  Citv  M  ,         "'''  ^''''^'  ^^^i'-h 

Dr.  Laro  que  "^;f  r^'^'f   '"  ™"--'tation  with 
and  papu  r ns    '    '  ".'''■:'''"'*^-    ''"'^^' "-ttled 

-yot!n.m::t::rth:;;:p^^"7- 

I"c-a.sesof  hc-emorrha^ie  smallnov   th^    r 

the  svmptoms  do  not  differ  snl,lT"'";'"' 
of  h.mon-ha,ic  scarlet  f.Z  7  Z  '' 
P--pura-the  morbus  macul„us  We,S'"r 
IS  rare,  however,  for  cases  t^  I  u  '  '' 
fourth  day,  and  e^en  wh^Tt  ,e  sk.nis  T  '"^ 
Purptiric.  the  papules  „,ay  t  ,"  ""'^°r!^' 
about  the  wrists.  In  only^ne- of  [J rmv"'"'' 
^  of  hemorrhagic  smil,  p..  ^^^-:- 


f^ 


•Canada  Medical  and  .Surgical  Jou„ul,  .875. 


L-Xxxiv^ 


\' 


if 


If 

'I 
ii 


98 


THE  MEDICAL  STANDARD 


small  pox  department    <.f     the    (.eneral    Il-.s- 
pital3  ditUleath  occur  on  the  tlurd  day.     Ihe 
most    careful    inspection    failed   to   detect  any 
papules.     In  three  cases  in  Nvhich   death   took 
place  on  the  fourth  day.  the  charactenstR-  rash 
was  beKi.minK  to  appear.     When  an  ep.denA.c  ,s 
prevailing,  there  is  rarely  any  difliculty  ^^^  chaR- 
nosiuK'  this  so-called  black  small  pox.  but  m  iso- 
lated cases  it  may  be   impossible,  if   a  papular 
rash  do  not  develop  before  death. 

The  prodromata  of  small  pox  are  very  char- 
acteristic and  of  Kreat  service  in  diagnosis  m  the 
early  stage.     I  saw  only  one  case  of  mistaken 
diagnosis     in     pu-ptiric    small    pox.     A    f"^"-- 
vear-old  clvld  was  taken  ill  suddenly  with  fever, 
great  pains  in  the  back  and  head,  and  on  the 
second  or  third  day  petecchia.  appeared  on  the 
skin      The    nervous    symptoms  were  marked; 
there  was  retraction  of  the  head  and  rigidity  of 
the  limbs.     The  cutaneous  hemorrhage  became 
more  abundan'  and  the  case  was  regarded  as 
one  of  cerebro-s.^^ial  meningitis.     Ha-matemesis 


occurr.;d  and  death  followed  on  the  si.xth  ,l;u 
The  child  had  not  been  vaccinated.  At  ih 
autopsy,  the  papules  could  readily  be  detcrt,, 
1,1  the  deeiilv  ha-morrhagic  skin,  and  this  lac 
with  the  absence  of  the  lesions  of  cerebro-spr 


nil 

IKM 


the 


meningitis,  led  to  the  postmortem  diag 
of  small  pox.  which  was  confirmed  by 
mother  taking  the  disease,  of  which  she  unfnri 

nately  died. 

In  the  pustular  stage  it  would  scarcely  s.« 
possible  to  make  a  mistake,  but  1  had  one  i;,. 
sent  to  me  in  which  diagnosis  of  small  i>(.x  hs, 
been  made.  The  history,  the  distribution  (clmi! 
on  trunk  and  covered  portions  of  limbs,  sparin 
the  face  and  hands),  left  no  doubt  that  it  was  a 
unusuallv  well  developed  pustular  syphilulc. 

The  diagnosis  of  small  pox  from  varicella 
not  always  easv.  In  1885,  the  Chicago™ 
which  conveved  the  disease  to  Montreal,  wa 
regarded  as  varicella  and  not  isolated;  an  im 
which  was  directly  responsible  for  one  of  li 
most  fatal  of  modern  epidemics. 


nv  t.; 


The  term  "Winter  Cholera"  isa  misnomer-a 
relic  of   the  time   when   "Break-bone   Fever. 
••Black  Measles."    '  Winter   Fever,"  "  Spine-in- 
the-Back"  and   similar   nosological  terms  were 
invented;  terms  as  vague  in  meaning,  very  often 
as  are  the  theories  of  the  fathers  in  medicine  and 
theology.     Whether  this   term    originated  with 
some  newly-fledged  graduate  of  a  moss-backed 
Chicago  or  Eastern  medical  school,  or  with  the 
cut-and-dried  remnant  of  other  days  in  Egypt  or 
Kentucky,  cannot  be  determined.      At  any  rate, 
it  is   not   a   proper    designation  for  a   disease 
whose  pathology  is  so  comparatively  well-known. 
••Choleraic  Diarrh.ra"  perhaps  comes  nearest  to 
filling  the  demand;  of  nomenclature;  the  qualify- 
ing phrase,  "  of  w.nter."  "  of  summer,"  "  of  the 
Chicago    River."   "'of   the   Mississippi  '    would 
clearly  designate  the  disease 


"CHOLERAIC  DIARRHCEA." 

WHEEI.l'.R   JONES,  M.  D.,  DANVILl-E,  ILL. 

followed  by  numerous  cases  of  diarrhoea,  assu: 
ing  all  the  phases  and  types  of  the  summer  d 
order,  from  the  simple  •'biliousness"  of  a  s!^ 
"ague"  to  the  collapsing  cases  and  rice  w 
discharges  of  true  serous  flux. 

The  predisposing  causes  are  similar  m 
seasons;  the  vitality  is  reduced  below  the 
of  successful  resistance,  which  reduction  is 
complished  as  readily  by  extreme  cold  » 
properly  applied,  as  by  excessive  heat.  The 
sisting  powers  of  the  constitution  being  thiii 
feebled  from  whatever  cause,  improper  food 
congestive  disorders  easily  induce  intes 
fluxes  in  all  grades  and  forms  of  action. 

One  very  common  source  of  malarial  d 
bance  in  the  country  and  in  country  t 
which  is  generally  overlooked,  although  ;tj 
duces  much   diarrhoea   of  special  types,' 


jarly  designate  the  disease.  presence  of  those  former  reservoirs  calledc 

The  large  majority  of   cases  depend     nn.       pre  e,  .^^^^^^^_^  ^^^^ 


prudence  in  diet  and  malaria.     The  processes  of 
food  fermentation,  the  ptomaines  and  the  germs 
of   zymotic  diseases  have  to  answer  for  most  of 
these  diseases  in  summer  and  winter.     The  only 
differences  are  such  as   would  necessarily  arise 
from  seasonal  iniluences.     Dirty   surroundings 
filthy  homes,  debused  and  uncleanly  habits,  each 
and  all,  predispose  to  the  disease  in  winter  as  in 
summer.      In  this  extremely  variable   climate 
where  a  variaticri  of   60°  F.   m.-^y  occur  in  24 
hours,  I  have  often  noticed  that  a  few  days  ex- 
tremely cold  weather  would  be  accompanied  or 


From  thes-^  arises  a  steady  influence  \vhic| 

duces  a  toxaemia  in  the  inhabitants  abovej" 

fested  bv  many  odd   forms  of  disease  ojI 

phcable'on  the  hypothesis  of  a  paresis  with 

accompanving  loss  of  function  and  resisting  c^ 

pacity     These  demand  certain,  prompt,  decisis 

treatment  if  a  fatal  issue  is  to  be  averted,  whethc 

the  loss  of  nerve  force  be  due  to  heat,  cold, ' 

blood  poison.      The  underground   air-currer. 

laden  with  gases  and  disease  germs  held  in 

straint  by  the  snow,  ice  and  frozen  ground  abu 

find  outlets  into  cellars  where  they  are  the  p 


THE  MEDICAL  S  VAyDARD 


U    ()(     the    r.cneral    Hos- 
r  on  the  third  day.     The 
:tion    (ailed  to  deti't  any 
•ases  in  which  ileath   tooV: 
lay,  the  .  liaracteristic:  rash 
u'ar.     When  an  epidemic  is 
arelv  any  ditTiculiy  in  diaR- 
blai'k  small  pox.  but  in  iso- 
•c    impossible,  if    a  papular 
before  death. 

,f  small  pox  are  very  char- 
at  service  in  diajjnosis  in  the 
only  one  case  of  mistaken 
,uric    small    pox.     A    f"i>'-- 
aken  ill  suddenly  with  fever, 
,ack  and  head,  and  on  the 
petecchia-  appeared  on  the 
s    symptonw  were  marked  ; 
.  of  the  head  and  rigidity  of 
aneou.^  hiemorrhage  became 
I  the  case  was  regarded  as 
d  meningitis.    Hit-matemesis 


occurred  and  death  followed  on  the  Mxthd. 

The  child  had  not  been  vaccniated.  At  h- 
autopsy.thepapulescouldrcad,lybede^cc. 
in  the  deeply  l^^^-m.-rrhagicsku,  and  th.sf.ut, 
with  the  absence  of  the  lesions  of  eerebro-sp,n„ 
nieningitis,  led  to  the  postn.a'tem  d.j^n,.- 
of  small  pox,  which  was  conhrmed  b>  t„e 
mother  taking  the  disease,  of  which  ^hcnnlnn.^ 

natelv  died. 

In  the  pustular  stage  it  would  scarctl>  v 
possible  to  make  a  mistake,  but  I  had  one 
sent  to  mc  in  which  diagnosis  of  small  poxl>.. 
been  made.   The  history,  the  distribut.on  (cbir, 
on  trunk  and  covered  portions  of  limbs,  sp;m,; 
the  face  and  hands,,leftm.  doubt  that  n  was. 
uuusuallv  well  developed  pustular  syphilid. 
The  diagnosis  of  small  pox  from  varuc- 
„,  ,Kvays  easy.     In     ,885.  the   Chicag,.  .. 
,vhich  conveyed  the  disease  to  Montr.al. 
re^ard<-d  as  varicella  and  not  isolated;  an. 
which  Wis   directly  responsible   for  one  ot 
most  fatal  of  modern  epidemics. 


'CHOLERAIC  DIARRHd'A." 


HY   C.   WHKKI.K.R  JONKS, 

IX  Cholera"  is  a  misnomer— a 
when   "Break-bone   Fever," 
•  Winter   Fever,"  "  Spine-in- 
lilar   nosological  terms  were 
vague  in  meaning,  very  often, 
01  the  fathers  in  medicine  and 
;r  this   term   originated  with 
I  graduate  of  a  moss-backed 
1  medical  school,  or  with  the 
uint  of  other  days  in  Egypt  or 
DC  determined.      At  any  rate, 
■r    designation  for  a  disease 
so  comparatively  well-known, 
sa"  perhaps  comes  nearest  to 
;  of  nomenclature;  the  qualify- 
nter,"  "  of  summer,"  "  of  the 
"of  the   Mississippi"   would 
he  disease. 

,rity  of  cases  depend  on  im- 
nd  malaria.  The  processes  of 
,  the  ptomaines  and  the  germs 


M.D.,  D.\NVII.1.K,  U.1-. 
followed  by  numerous  cases  of  diarrhcea,  ass: 
ing  all  the  phases  and  types  of  the  summer 
order,  from  the  simple  "biliousness  of  a  .. 
"ague"  to  the  collapsing  cases  and  rice « 
discharges  of  true  serous  tlux. 

The  predisposing  causes  are  similar  m, 
seasons;   the  vitality  is  reduced  below -k!! 
of  successful  resistance,  which  red."  uoii 
complished   as   readily  by  extreme  .old 
properly  applied,  as  by  excessive  heat. 

sisting  powers  of  the  constitution  being  1^^ 
feebled  from  whatever  cause,  improper  fooi 
congestive  disorders  easily  induce  inte 
rtuxes  in  all  grades  and  forms  of  actu>n. 

One  very  common  source  of  malarial  u 
bance   in   the   country  and   in   country! 
which  is  generally  overlooked,  although 
duces  much   di.arrhoea  of  special  type. 
presence  of  those  former  reservoirs  called. 
From  these  arises  a  steady  influence  whid 
duces  a  toxemia  in  the  inhabitants  abou 
f.«ted  bv  manv  odd   forms  of  disease^ 


ollowed  on  the  sixth  day, 
been  vaccinated.  At  tin- 
,.„uld  ri-adily  be  detc  tc>! 
■hauic  skin,  and  this  In: 
tie  lesions  of  cerebro-si>in;.. 
:he  postnioitem  diaKiio-i^ 
h  was  continued  I'v  tht 
sease.of  wliidi  -^'i'^  unlnri  • 

jj^rc  it  svoulil  scarcely  s"" 
Tiislakc.  but   1  had  one  .  ..- 
di.-iyjnosis  of  small  \)n\U 
,t()ry,thedisirilintion(chif'; 
;d  portions  of  limbs,  span';, 
,  left  no  doubt  that  il  w  a<  .^: 
l(,ped  pustular  syphilii!.- 
small   pox  from  varia 
In     1885,  the    Chicaijii  . 
,e  disease  to  Montrt'.-il.  . 
la  and  not  isolated;  am 
y  responsible    for  one  i<\ 
rn  epidemics. 


U.I-. 

rous  cases  of  diarrh(i-a,  a 

and  types  of  the  summer 
,imple  "biliousness"  of  a 
oUapsinR  cases  and  rice  w 
;  serous  tlux. 
ng  causes  are  similar  in 
lity  is  reduced  below  'in 
stance,  which  redmuon 
•eadily  by  extreme  cold 

as  by  excessive  heat.  Tr 
[  the  constitution  beiiitj  thr 
atever  cause,  improper  fooi 
)rders  easily  induce  inte 
les  and  forms  of  action.  ^ 
imon  source  of  malarial  d 
:ountry  and  in  country  i 
lily  overlooked,  although  1 
iarrhoea  of  special  type?. 
;e  former  reservoirs  calledi 
,es  a  steady  intlucnce  whic 
la  in  the  inhabitants  above, 
■  odd   forms  of  disease  « 


A'^^.«W/>.,„,TM.JouRXA,.o..N,.:,no,.s.vv 


^^5? 


"  M«..sr,A,,  DisKASK,  4/.,,,/,,  ,g 


GLIOMA   OF   THE   MEDULLA    OBLOP 


NGATA. 


^y  WILUAM  OSI.EK,   M.D., 


MOPKSSOR  OP  CLINICAL  MEDICINE    IN     ,,.. 

1887.     He  was  1  Lu  \         ^"^  ^^'^  °^  ^arch, 

gave  a  very  good  account  of  r"''r'  ""•""'■'"  "'^"'  ^^^ 
knew  little' fnotir;7L-f.^nrfH7  '''I''''''''  "^ 
^11  hi-s  brothers  and^sfster^  H  '  h.d  T'  "  """"^  ^"^ 
ago,   with  secondary  symptontf     W   ,    .,"''''  '^^°  ^'^''^''^ 

verysevereattack  of  heir  with,  •'  "'^'P^""  ^' ' 
been  well  until  six  or  ZlT       v  ""'''  *"  '^^^  he  has 

have  fits,  for  whi^h  e  f  ^  f,  ^f^'  "\""  '"  '^^"^"  *° 
Hospital,  where  he  ren^a;!;  d  '  :S'  Att  t'l^^"?:!^^"''^ 
one  or  two  attacks  a  week  ■  now  Z  ^^  ^^^  °"^y 

and  he  has  had  three  inl^;  "        "  V  ."T  '"^'^^"^'>'' 
feel  a  little  uncertain  on  hilfeet  "'^  '  ^'  '''^'"^  ^^^°  ^° 

Condition  on  the  6th.  when  fir«f  .» 
intelligent  and  answers     t. 'stLs"  ^pir^  C^^r^^  "^  '' 
headache,  unsteadiness  m,  w^lkln/ZT   ^'     ^^^'P'-'^''^^  of 
body,   and    fits.     There     snir^V         ''"'^^''°"^   ^^^'^  J^i^ 
grasp  of  the  hands  itL'I'   "''''"^'   "°  P-'^'^y-"-     The 
unimpaired.     He  co^;       f;  ^i:?;  ,'^^-"'-  P--^  of  legs 
muscles  of  the  back  of  the  nee  -    .nd  n        T  '"^  P^''"  ■"  ^'^^ 
the  head  and  back  stiffly,  butirnthe^hl'"^^  ?  !?'  ^^"'^^ 
to   side.     He   walks   Jtl      .  ^"""^  ''^^'^y  ^''^ni  side 

•'drunk.'-andheten   St  TlrT"     'f   ^'^^'^    ^'^   ^^^^ 
and  with  the  aid  of  an  assis  ant'.'  ^''      '^^'  ^'"''^  ^'°"^' 

scone  .no,.    ...„.:_     f '''^^"^  ^  ^""  ^vent  to  the  oohthalmo- 


t 
1 

3 

(1 
8 


9 
l| 

3 

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II 

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I 

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a 


Uf 


!| 


Hci 


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scope 


fully  100  feet  off.     Th 


!     f 


i||l 


e  co-ordination 


in  hands 


ill  ] 

!      i 


-  .  ! 


IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


// 


1.0    !r  Hi^  IM 


I.I 


45 

50 

t         1^ 


M 

2.2 


IL25  ill  1.4 


2.0 


1.6 


Pnotogrdphic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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■1>^ 


\\ 


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^ 


^ 


WILLI  AM  OSLEK. 

is  impaired,  he  does  not  grasp  objects  quickly,  nor  can  he 
rapidly  touch  the  tip  of  his  nose.  He  gets  out  of,  and  re- 
turns to  bed  with  great  deliberation,  like  a  man  with  lum- 
bago. Sensation  is  everywhere  retained  ;  feels  a  pin-prick 
rapidly.  Complains  of  m-mbness,  tingling,  and  cr  eping 
feelings  in  the  hands  and  feet.  Says  his  legs  "  feel  as  if 
something  had  laid  upon  them  and  put  them  to  sleep."  Has 
also  sensations  of  cold  in  hands  and  feet,  and,  to  use  his  own 
words,  "  they  are  warm,  but  they  feel  so  cold."  This  was  a 
very  frequent  complaint.  Sensation  in  region  of  fifth  nerve 
normal.  Special  senses  unimpaired  ;  he  hears  the  watch  well 
at  either  ear  ;  no  affection  of  taste  or  smell.  Vision  good. 
The  eye-grounds  were  examined  twice  ;  no  neuritis  ;  veins 
looked  full,  but  there  were  no  special  changes.  The  head- 
ache was  not  constant,  was  chiefly  occipital,  and  he  did  not 
seem  clearly  to  be  able  to  separate  it  from  the  painful  feel- 
ings of  stiffness  in  the  nape  of  the  neck. 

Reflexes  are  present ;  patellar  somewhat  exaggerated.  In 
the  fits  the  movements  are  bilateral ;  he  froths  at  the  mouth  ; 
says  he  does  not  lose  consciousness.  This  is  probably  a  mis- 
take. He  fell  out  of  bed  last  night  in  one  and  knocked  his 
head.  They  last  from  five  to  fifteen  minutes,  and  he  comes 
out  of  them,  as  a  rule,  with  the  mind  clear. 

The  appetite  is  good  ;  he  vomits  sometimes ;  bowels  reg- 
ular. There  is  a  loud  apex  systolic  murmur,  transmitted  to 
axilla,  and  the  pulmonary  second  sound  is  accentuated.  Pulse 
fair  in  volume,  90  per  minute.     Urine  clear  ;  no  albumen. 

Taking  into  consideration  the  fact  that  he  had  had  a 
chancre  two  years  ago,  the  lesion  was  thought  to  be  syphi- 
litic, and  he  was  given  large  doses  of  potassium,  iodide. 

On  the  7th  and  8th  he  was  better,  but  the  pain  in  the 
back  of  the  neck  was  severe.  On  the  9th  the  tingling  and 
numbness  of  hands  and  feet  were  not  so  distressing,  and  he 
had  less  headache.  Had  a  severe  convulsion  last  night. 
There  is  increasing  difficulty  in  getting  in  and  out  of  bed. 
Pupils  are  dilated  to-day.     He  talks  clearly  and  says  he  is 

improving. 

On  the  lOth,  at  12  o'clock,  he  was  given  a  dose  of  the 
ioJ.de  and  immediately  had  a  sort  of  fit,  but  he  did 


move 


,  nor  can  he 
t  of,  and  re- 
in with  lum- 

a  pin-prick 
nd  cr  aping 
3  "  feel  as  if 
sleep."  Has 
•  use  his  own 

This  was  a 
3f  fifth  nerve 
le  watch  well 
Vision  good. 
:uritis  ;  veins 
;.  The  head- 
id  he  did  not 
;  painful  feel- 

^gerated.  In 
.t  the  mouth  ; 
obably  a  mis- 
i  knocked  his 
and  he  comes 

;  bowels  reg- 
ransmitted  to 
tuated.  Pulse 
)  albumen. 
e  had  had  a 
t  to  be  syphi- 
,  iodide, 
e  pain  in  the 
tingling  and 
issing,  and  he 
)n  last  night. 
i  out  of  bed. 
nd  says  he  is 

a  dose  of  the 
did  not  move 


GL/OMA    OF   THE  AfEDULLA    OBLOA'CATA. 

the  hands      At  12.45  I  came  into  the  ward  and  found  him  t 

the  foilowmg  condition :   Is  unconscious       R.         . 

slow,  three,  four,  and  five  in  ZZZl      ^''^''T''"  ""'''' 

;7f.-^.ft;expiration'r:::,„:;:^'^t;:r;:::- 

08.  fair  m  volume.     At  1.3.55  the  respirations  had  fllleHo 
two  m  tne  minute,  and  pulse  stopped  somewh      suddenly 
No  heart-beat  or  heart-sound  could  be  detected  af  er  12    ^' 
Last  mspiration  at  i  o'clock.  ^^^" 

Autopsy. -Twenty-four  hours  post  mortem.     Old   scar, 
on   orehead  and  arms.     Calvaria  normal,  perhaps  a  1  i t tt  hick 

is    lline  o?  f     . YT  '  ^'"—y  fun-on  either  sio.  there 
ear  ah.       ^'^ff^.-'^^'^/^^  pachymeningitis.     Arachnoid    is 
clear  at  base.      Ve.ns  of  pia  dilated  and  full.     Parts  at  base 
present  foilowmg  condition  :  Olfactory  and  optic  nerves  sma, 
but  h,,e  normai  color.     No  effusion  in  interpeduncular  spac  ' 

Vessels  of  crcle  of  W.lhs  contain  blood  ;  they  are  not  athe 
romatous.     The  third,  fourth,  and  fifth  nerves  look  nlna  ' 
and  those  emerging  from  the  lateral  part  of  medulla  ha;e  a 
natural    appearance.      The   crura   were   cut.    and    ce.ebrun' 
removed  separately.     Vessels  on  the  cortex  very  fu        "ay 
■natter  of  p.nk-red  color.     White   matter    in  section     l^T 
moist   and    glistening;   no   foci   of  dis^k'^Thf     ;,;:,: 
contam  a   shght  excess  of  fluid  ;  linin.  membrane  norm 
Crura  show  no  change.     Pons  normal.     The  fourth  ventHct 
-s  d.lated,  particularly  in  the  lateral  recesses.     The  Falbpian 
aqueduct  not  enlarged.     The  floor  of  the  ventricle  looks  noT 
mal  above  the  level  of  the  acoustic  stri.,  the  right  of  whTch 
are  not  so  d.st.nct  as  the  left.     A  large  vein  curls  ov  r   he 
left  margm  of  the  medulla  at  the  level  of  the  left  stri^ 

The  lower  part  of  medulla  ana  beginning  of  the  cord  are 
occupied  by  a  large  growth  extending  from  below  the  call 
mus.  projectmg  more  on  the  left  than  on  the  right  sid        ft  is 
everywhere  covered  by  pia.     On  the  left  side  it'has  a  redH.U 

sta^l"  jr  T^""'''  °"  *^^  nght  side  the  white  sub- 
stance of  the  medulla  .s  apparent.  No  trace  to  be  seen  of 
restiform  bodies  or  of  posterior  pyramids.  The  olivary  bodies 
are  v.s.ble,  but  wider  apart  than  normal,  and  tne  lower  pa 


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WILLIAM    OSLEN. 


absorbed.     The  growth  retiches  to  within  7  or  8  millimetres  of 
the  fissure  separating  the  medi'.la  and  pons. 

The  cerebellum  is  a  little  compressed  just  above  the  tumor. 


Fig.  I. — Section  tliroiigh  the  Tumor 
below  level  of  Calamus.  Natural 
size. 


Fig.  2.  — Sectior.  through  the  Olivary 
Bodies  and  uppermost  portion  of 
the  Tumor. 


No  other  changes.  The  upper  part  of  cervical  cord  is  soft 
and  the  postero-lateral  columns  have  a  very  translucent  aspect. 
The  central  canal  is  somewhat  dilated.     A  cross-section  just 


1^ 


Fig.  3. — Section  at  the  edge  of  tlie  Growth,  showing  the  gliomatous  tissue  and  dis- 
tended Blood-vessels  Nos.  7  and  3. 

below  the  calamus  has  the  appearance  represented  in  Fig.  i 
(actual  size).  The  tumor  is  an  inch  in  breadth  by  three- 
fourths  of  an  inch  in  antero-posterior  diameter.  In  fully  one- 
half  of  the  circumference  it  is  in  contact  with  the  pia  mater 


GUOMA    OF    THE   MEDULLA    OBLONGA 


TA. 


aid  fl  .   '  ',"    ^'  *■"'  ""^  '^'  '''''"''  ^''^h  the  compressed 

and  flattened  columns  of  the  cord.     In  the  medulla  it  does  not 
reach  above  the  middle  of  the  olivary  bodies  ;  Fig.  2  repre 
sents  the  section  at  this  level.     The  tumor  was  firm    of  a  r'ed- 
brown  color.  w,th  recent  hemorrhages  into  its  substance.    The 
large  lacunae  represented    in  Fig.    i   were    filled  with  clots 
H.stolog.cally   as  shown  in  Fig.  3,  the  tumor  is  composed  of  a 
troma  of  nucleated  fibre-cells  supporting  blood-vessels  which 
m  places  are  so  closely  set  that  the  appearance  is  that  of  an 
angioma      In   other  regions  the  gliomatous  tissue  is  more 
dense  and  the  blood-spaces  less  numerous 

rh.>?\'r'''°"  °^  '^'"  '"'^°'''  pushing  aside  and  compressing 
chiefly  the  posterior  columns,  explains  the  disturbances  of 

feaTurerofTh'  ''"  '"7-°'^^'-'^^-"  -hich  were  the  prominent 
features  of  the  case.  It  is  probable  that  the  central  hemor- 
rhages, which  looked  recent,  caused  death  by  increasing  the 
pressure  and  disturbing  the  respiratory  and  cardiac  centres 
which  lay  just  above  the  growth. 

Gliomata  of  the  medulla  are  rare.     Sokoloff  has  recently 
1  Wure  ^  '"'''*  '""^ ''"'  '^""'''"^  '"''""  '"''""'^^^  ^•■°"^  ^he 


♦  Deutsches  Archiv.  f.  klin.  Medicin,  B.  xli.,  H.  5.  ,887. 


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TYPHLITIS  AND  AI^: 

By  WILLIAM  OSLER,  M.D.,  F 
Professor  of  Clinical  Medicine  in  the  Univ 
(Reprinted  fnyin  Tub  Canada 
Caecal  and  peri-cmcal  inflammations  are  descrihed 
under  the  various  tern.s  typhlitis,  peri-fcyphlit,is, 
para-typhhtis,  peri-cecal  abscess,  and  appendicitis. 
I  think  we  may  clinically,  and  for  practical  pur- 
poses distinguish  two  groups  of  cases,  to  the  first 
of  which  the  name  tj^phlifds  may  be  restricted,  and 
o  the  second  appen<Uciti,,  or,  perhaps,  better,  as 
Ur.  litz  suggests,  perjorative  appendicitis. 

7^^phms.-By  this  we  understand  inflammation 
of  the  c«cum.     The  term  has  also  been  used  to 
designate  inflammation  of  the  contiguous  parts  as 
well;  but  ,t  may  be  limited  to  the  cases  in  which 
the  caput  ceci  and  the  adjacent  portion  of  the 
ascending  colon  are  involved.     Unfortunately,  we 
know  nothing  of  the  anatomical  condition  described 
under  this  term.     1  have  my.elf  never  seen  a  post 
mortem,  nor  do  I  know  of  a  report  in  which  the 
disease  was  confined  strictly  to  the  walls  of  the 
intestine  in  these  regions. 

The  cases  are  commonly  met  with  in  youna  per 
sons,  particularly  in  young  males.      The  attacks 
are  very  often  associated  with  errors  in  diet      In 
the  majority  of  cases  there  is  a  history  of  cnnsti 
pation.     The  symptoms  are  very  distinctive     The 
patient  complains  of  pain  in  the  right  iliac  fossa  • 
there  IS  constipation  and  often  nausea-sometimes' 
vomiting.      At  first  there  may  be  no  fever,  bu 
subsequently   the   temperature    rises    from    100= 
0  102  .     On  examination,  the  patient  is  usually 
found  with  the  right  thigh  flexed  on  the  abdom  n 
There  is  slight  fullness  in  the  right   iliac  foss!  • 
^ndernesson    pressure,   and,  often,  dullness  on 
P  rcus.ion.     In  the  majority  of  instances  there  i 

tTz  ::t:'  "''^'^  "-^^  ''^-  ^  -»»ded 

outline,  so  that  *h"  — ».-    • 
tunm.."  h     "u  -^F^'^^^'on    "sausage-shaped 

tumoi      has  been  applied  to  the  condition.     Such 
cases  are  extremely  common,  and  are  usually  re 
garded  (no  doubt  properly)  as  the  result  of  fLal 
'^'paction -typhlitis  stercoralis.      With   prope 


•  The  subatance  of  remarks  made  at  the  Toronto  Medical 
■ -Society,  Deoemb€r26,1888.  ^"«"'cai 


treatmi 
tions— 
found 
fascal  1 
Purgat: 
a  rule, 
Atta 
the  sail 
recurre 
little  (k 
fecal  in 
the  inte 
sues  in  t 
there  n 
coats, 
round 
forationl 
cjBcal  a 
in  flam  n 
tis;;ue 
■^  '.  'be 
witl  th 
have  no 
there  h 
ease  of 
The 
widely 
describ 
ease;  t\ 
cases  t 
great  d| 
clinical 
typhliti 
Philad 
a;t.  22 
a  furrec 
On  exai 
iliac  fos 
the  righ 
and  pre." 
nite  oul 
admissi 


and  large  enemata  P^* 
pain   was  not  cxces' ' 
away  a  niiiiii)er  of  h*** 
p(!r;itni(.  on  I  lie  thirf*"* 
tioM  and  tt'iuleine.ss  ^' 
the  sixth  day  the  .'.,"' 
Md»>s  w;is  i'([ual,  and^ 
•  luitc    well.       He   hi' 
weeks  iM'forn.     Sucl'*'' 
whatever  the  niorbi'^ 
they  po.s.scss  feature*" 
the  next  group.         ^^ 

Appi-ndlcilis.-  ~h\   ' 

lesion   proceeds   froi 

ti( 


which   is   liable  to 
inflammation,    catar 
obliteration  of  the  i 

i    I 

tube,  and  perforatic 

lodge  in  it,  and  fa'c 

become  hardened  an 

enteroliths. 

In  a  recent  repoi, 

«th,  lS88)Igaven. 

bad   mot  with  ulcer 

connection  with  pht 

^    er 
never  met  with  for  ■ 


it 


er 
)o 


m 
3a 


On  one  occasion  tiv 

me  as  having  been 

the  tube,  in  a  dissec , 

of  the  cases  in  the  p 

es 
treal  General  Hospi  ' 

acting  as  Patliologi, 

presence  of  six  or  eii 

of  a  man  dead  from 

blance  of  the  small 

quently  leads  to  ern 

Inflammation  anc 

vermit'orniis  (so  long 

may  produce  no  de 

iJe  the  most  extensi' 

bo  completely  oblitc 

dlMhMition,  without 

Kigns  of  abdominal  c 

If  the  appendix  is., 

ulceration  may  go  (i 

tube  forming  attach 

exceptional.     More 

the  perforation  lead: 

ation  of  which  will 


!f 


i  i 


in 


i.K)iX  V  au 


TYPHLITIS  AND  A  f>PE  N  D  IC  IT  I  S.* 

Bv  WILLIAM   08LKR,  M.D.,  B'.R.CR,  Loni... 

Professor  of  Clinical  Medicine  in  the  University  of  Fennsylvuniii. 

(Reprinted  /rein  Tin  Canada  Lanort,) 

Csecal  and  peri-cneca!  inflammations  are  described  treatment,   recovery  is   fl„.  rule      Local  applica 

under  the  various  ter.ns   typhlitis,   peri-typhlitis,  tions-tho  ice-l.ag,  turp.nCno  stupes-are  usually 

para-typhlitis,  peri-ciecal  abscess,  and  appendicitis.  found  sutlicient  to  ullay  pan,      To  break   up  the 

I  think  wo  may  clinically,  and  for  practical  pur-  fu'cal    masses,    large    i..j..,t,„ns    should    be    usod 

poses, distinguish  two  groups  of  cases,  to  the  first  Purgatives  may  be  administored,  but  I  prefer  as 

of  which  the  name  typhlith  may  be  restricted,  and  a  rule,  to  rely  on  largo  injciions 


to  the  second  appewiicitis,  or,  perhaps,  better,  as 
Dr.  Fitz  suggests,  perforative,  appendicitis. 

Typhlitis. — By  this  we  understand  inflammation 
of  the  caecum.  The  term  has  also  been  usad  to 
designate  inflammation  of  the  contiguous  parts  as 
well ;  but  it  may  be  limited  to  the  cases  in  which 
the  caput  c^eci  and  tiie  adjacent  portion  of  the 
ascending  colon  are  involved.  Unfortunately,  we 
know  nothing  of  the  anatomical  condition  described 
under  this  term.  1  have  myself  never  seen  a  post- 
mortem, nor  do  I  know  of  a  report  in  which  the 
disease  was  confined  strictly  to  the  walls  of  the 
I  intestine  in  these  regions. 

The  cases  are  commonly  met  with  in  young  per- 
jsons,  particularly  in  young  males.      The  attacks 
lare  very  often  asso  iated  with  errors  in  diet.     In 
[the  majority  of  e  s(  ,  there  is  a  history  of  consti- 
pation.    The  symptoms  are  very  distinctive.     The 
patient  complains  of  pain  in  the  right  iliac  fossa ; 
Ihere  is  constipation  and  often  nausea— sometimes 
Vomiting.      At  first  there  may  be  no  fever,  but 
lubsequently   the   temperature    rises    from    100° 
'  102°.     On  examination,  the  patient  is  usually 
Pund  with  the  right  thigh  flexed  on  the  abdomen, 
there  is  slight  fullness  in  the  right   iliac  fossa ; 
Vderness   on    pressure,   and,  often,  dullness  on 
fercussion.     In  the  majority  of  instances  there  is 
ptinct  induration,   which   may  have  a  rounded 
■UUine,  so  that  the  expression    "sausage-shaped 
^mor  "  has  l^een  applied  to  the  condition.     Such 
'ses  are  extremely  common,  and  are  usually  re- 
ferded  (no  doubt  properly)  as  the  result  of  fsecal 
npaction  _  typhlitis  stercoralis.      With   proper 

[The  Bubetance  of  remarks  made  at  the  Toronto  Medical 
J^pciety.  December  26.  1888. 


Attacks  of  this  kind  may  repeatedly  occur  in 
the  same  patient;  I  hiivc  known  of  four  or  five 
recurrences  within  four  y.-a.s.     There  can  be  very 
little  doubt  that  this  l..,ul  inflammation  is  due  to 
fuical  impaction.     Tlit;  iiitla.Niiiation  is  confined  to 
the  intestinal  wall,  and  rarely  extends  to  the  tis- 
sues in  the  neighborhood.  Itis  true, that  occasionally 
there  may  be  more  serious  disease  of  the  c«)cal 
coats.       I   have   put  on  rotord  two  instances  of 
round  ulcer  of  the  caecum,  in  both  of  which  per- 
foration  occurred,   with  the  production  of   peri- 
ciecal  abscess.     It  is  ([uit..  possible,  of  course,  that 
inflammation  may  exteiul  to  the  loose  connective 
tissue    behind   the   ciecuni  -  when   that  organ    is 
attached— and  even  go  on  to  suppuration.     But, 
with  the  exception  of  the  .uses  of  ulceration,  1 
have  no  personal  kuowlod^'c  of  instances  in  which 
there  has  been  peri-ciucal  al)5cess  apart  from  dis- 
ease of  the  appendix. 

The  opinion  has  been  exprt-ssed,  and  is  I  believe 
widely  held,  that  tlie  casps  such  as  I  have  here 
described  are  also  in  reality  due  to  appendix  dis- 
ease ;  that  typhlitis  and  peii  typlilitis  mean  in  all 
cases   tubal   affection.      1   confess  there  is  often 
great  doubt  as  to  the  true  nature  of  a  case,  but, 
clinically,  I  believe  we  can  recognize  a  stercoral 
typhlitis.     There  is  at  present  in  my  wards  at  the 
Philadelphia  Hospital  a  case  in  illustration.    Lad 
a-t.  22,  admitted  22hd,  with  temperature  of  102", 
a  furred  tongue,  constipati.jn  and  abdominal  pain. 
On  examination,  there  was  tenderness  in  the  ri  'ht 
iliac  fossa,  the  thigh  was  drawn  up  and  everted  • 
the  right  iliac  region  was  dull,  tender  to  the  touch,' 
and  presented  a  distinct  induration,  without  defi- 
nite outlines.     He  had  nausea  and   vomiting  on 
admission.     Stupes   and   poultices   were  applied 


'/ 


^         ml  liirgf  cnomata  wore  j^iven  ;  no  opium,  us  the 

iaiu  was  not  excessive.     The  injeotiona  brought 

way  II  miiiilier  of  hard  tWal  masses.     Tlie  tern- 

pciatiiif  (111  Ihe  third  day  was  normal,  the  indiini- 

(if)ii  .111(1  ttMidcriiess  gradually  disappearod,  and  on 

iIk!  sixth  day  the  stmse  of  re.sistance  in  the  two 

•  11  •J  ^ides  was  o(jual,  and  the  patient  said  that  he  felt 

|iiite   wt'll.       Ife   liad    had   a  similar   attack   six 

u(>pks  before.     Such  cases  we  have  all  seen,  and 

svliatcver  the  morhid  condition  may  be,  I  th-nk 

I  hey  possess  featuies  which  separate  them  from 

I  lie  next  ;,'roup. 

Appmikilis.  -\n  the  second  group  of  cases  the 
lesion  proceeds  from  the  appendix  vermiformis, 
which  is  liable  to  various  affections- -catarrhal 
inflammation,  catarrhal  ulceration,  obliteration, 
obliteration  of  the  proximal  end,  dilatation  of  the 
tube,  and  perforation.  Foreign  bodies  may  also 
lodge  in  it,  and  fieces  moulded  to  the  tube  may 
i)ecome  hardened  and  calcified  so  as  to  form  small 
enteroliths. 

In  a  recent  report  (Med.  and  Surg.  Rep.,  Oct. 
Gth,  IJ^HH)  I  gave  notes  of  eleven  cases  in  which  I 
had  met  with  ulcers  in  the  appendix,  usually  in 
connection  with  phthisis  or  typhoid  fever.  I  have 
never  met  with  foreign  bodies  in  the  appendix. 
On  one  occasion  fivo  apple  pips  were  brought  to 
me  as  having  been  found  in,  and  removed  from 
the  tube,  in  a  dissecting. room  subject ;  and  in  one 
of  the  cases  in  the  post-mortem  books  of  the  Mon- 
treal General  Hospital,  Dr.  Sutherl«ind  (who  was 
acting  as  Pathologist  in  my  absence)  records  the 
presence  of  six  or  eight  snipe  shot  in  the  appendix 
of  a  man  dead  from  Bright's  disease.  The  resem- 
blance of  the  small  enteroliths  to  date-stones,  fre- 
(juently  leads  to  error. 

Inflanniiation  and  ulceration  of  the  appendix 
vermiformis  (so  long  as  it  is  confined  to  this  tube) 
may  produce  no  definite  symptoms.  There  may 
be  the  most  extensive  ulceration,  the  lumen  may 
be  completely  oblit(irated,  there  may  be  extreme 
distention,  without  the  patient  manifesting  any 
signs  of  abdominal  disorder. 

If  the  appendix  is  quite  free,  it  is  possible  that 
ulceration  may  go  on  to  perforation,  without  the 
tube  forming  attachments.  This,  however,  is  very 
exceptional.  More  commonly  adhesions  form  and 
the  perforation  leads  to  localized  abscess,  the  situ- 
ation of  which  will  depend  upon  the  position  of 


this  extremely  variable  structure.  It  is  n\08t 
commonly  situated  in  the  right  iliac  fossa,  and  is 
either  within  the  peritoneum,  when  the  appendix 
is  entirely  surrounded  by  this  membrane,  or  it  is 
behind  the  peritoneum,  when  the  appendix  (which 
is  rarely  the  case)  has  only  a  partial  serous  cover- 
ing. I  have  seen  peiforation  o(;cur  with  the  for- 
mation of  localized  abscess,  within  the  pelvis  in 
the  neighborhood  of  the  broad  ligament  ;  in  ano- 
ther instance  immediately  upon  the  sacrum,  the 
tip  of  the  appendix  lying  to  the  left  of  the  middle 
line  ;  and,  in  a  third  instance,  the  abscess  was  high 
up  behind  the  mesentery  upon  the  psoas  muscle. 

I  do  not  think  that  sufficient  stress  has  been 
laid  upon  the  fact,   that  this  local  inflammatory 
process  almost  invariably  precedes  the  graver  man- 
ifestations.    That  healing  may  take  place  at  this 
stage,  is  shown  by  the  occurrence  of  an  obliterated 
tube  closely  adherent  with  fibroid  thickening  and 
much    pigmentation   of    the   surrounding    tissue. 
Once  perforation  has  occurred  with  abscess  forma- 
tion, the  course  is  extremely  variable.   It  is  within 
the  experience  of  almost  every  physician  to  have 
seen  the  pus  appear  anteriorly  in  the  neighborhood 
of  the  groin,  where  it  may  open  spontaneously. 
The  presence  of  gas,  or  even  small  fragments  of 
fieces,  may  shov,-  that  there  is  open  communication 
with  the  bowel.     Two  such  oases  I  saw  with  my 
preceptor.  Dr.    Holford    Walker,    of  Dundas,   in 
1866  and  1869.     One  of  these  cases  made  a  good 
recovery  ;  the  other,  with  much  more  extensive 
abscess  formation  and  perforation  in  several  places 
(through  which  gas  discharged),  succumbed  to  sep- 
tic fever.     That  the  tube  of  the  appendix  is  not 
always  obliterated  at  its  caHJal  end  before  perfora- 
tion occurs,  as  is  claimed  by  some  writers,  is  shown 
by  such  cases.     The  pus  may  burrow  and  appear 
in  the  lumbar  region,  or  it  may  pass  down  and 
appear  in  the  peritoneum  and  form  a  peri-rectal 
abscess.      A  more  favorable  event  is,   when  the 
abscess  perforates  into  a  neighboring  viscus— the 
colon,  the  crecum,  the  rectum  or  the  bladder.     In 
a  recent  report  of  a  case  in  a  French  Journal,  in 
which  the  abscess  perforated  into  the  bowel,  the 
characteristic  oval  enterolith  was  found  with  the 
discharged  pus  and  fseces.     Perforation  into  tli^ 
bladder  is  less  common.    At  the  Montreal  Genera! 
Hospital,  in  the  Summer  session  of  1882,  IJecturcd 
upon  two  cases  in  which  this  event  occurred  with 


were  fifiven  ;  no  opium,  as  the 
sive.  The  injections  brought 
lard  ftocal  masses.  Tlie  tern- 
1  day  was  normal,  the  indura- 
Sjradually  disappeared,  and  on 
,inse  of  resistance  in  the  two 
the  patient  said  that  he  felt 
td  had  a  similar  attack  six 
^1  cases  we  have  all  seen,  and 
d  condition  may  be,  I  think 
{s  which  separate  them  from 

the  second  group  of  cases  the 
'.  n  the  appendix  vermiformis, 
i  various  affection."  —catarrhal 
irhal  ulceration,  obliteration, 
itroximal  end,  dilatation  of  the 
\m.  Foreign  bodies  may  also 
.les  moulded  to  the  tube  may 
d  calcified  so  as  to  form  small 

■t  (Med.  and  Surg.  Sep.,  Oct. 
»tes  of  eleven  cases  in  which  I 
s  in  the  appendix,  usually  in 
lisis  or  typhoid  ft  ver.  I  have 
sign  bodies  in  the  appendix. 
3  rpple  pips  were  brought  to 

found  in,  and  removed  Trc:" 

ting. room  subject;  and  in  one 

OBt-mortem  books  of  the  Mon- 

Ital,  Dr.  Sutherl«ind  (who  was 

8t  in  my  absence)  records  the 

wht  snipe  shot  in  the  appendix 

B  right's  disease.     The  resem- 

enteroliths  to  date-stones,  fre- 

or. 

I  ulceration  of  the  appendix 
I  as  it  is  confined  to  this  tube) 
ifinite  symptoms.  There  may 
Ve  ulceration,  the  lumen  may 
irated,  there  may  be  extreme 

the  patient  manifesting  any 
lisorder. 

j  quite  free,  it  is  possible  that 
)n  to  perforation,  without  the 
inents  This,  however,  is  very 
commonly  adhesions  form  and 
J  to  localized  abscess,  the  situ- 

depend  upon  the  position  of 


this  extremely  variable  structure.  It  is  most 
commonly  situated  in  the  right  iliac  fossa,  and  is 
either  within  the  peritoneum,  when  the  appendix 
is  entirely  surrounded  by  this  membrane,  or  it  is 
behind  the  peritoneum,  when  the  appendix  (which 
is  rarely  the  case)  has  only  a  partial  serous  cover- 
ing. I  have  seen  pei  foration  occur  with  the  for- 
mation of  localized  abscess,  within  the  pelvis  in 
the  neighborhood  of  the  broad  ligament ;  in  ano- 
ther instance  immediately  upon  the  sacrum,  the 
tip  of  the  appendix  lying  to  the  left  of  the  middle 
line  ;  and,  in  a  third  instance,  the  abscess  was  high 
up  behind  the  mesentery  upon  the  psoas  muscle. 

I  do  not  think  that  sufficient  stress  has  been 
laid  upon  the  fact,  that  this  local  inflammatory 
process  almost  invariably  precedes  the  graver  man- 
ifestations.    That  healing  may  take  place  at  this 
stage,  is  shown  by  the  occurrence  of  an  obliterated 
tube  closely  adherent  witii  fibroid  thickening  and 
much    pigmentation   of    the   surrounding    tissue. 
Once  perforation  has  occurred  with  abscess  forma- 
tion, the  course  is  extremely  variable.   It  is  within 
the  experience  of  almost  every  physician  to  have 
seen  the  pus  appear  anteriorly  in  the  neighborhood 
of  the  groin,  where  it  may  open  spontaneously. 
The  presence  of  gas,  or  even  small  "fragments  of 
fiBces,  may  show  that  there  is  open  communication 
with  the  bowel.     Two  such  oases  I  saw  with  my 
preceptor.  Dr.    Holford    Walker,    of  Dundas,   in 
1866  and  1869.     One  of  these  cases  made  a  good 
recovery  ;  the  other,  with  much  more  extensive 
abscess  formation  and  perforation  in  several  places 
(through  which  gas  discharged),  succumbed  to  sep- 
tic fever.     That  the  tube  of  the  appendix  is  not 
always  obliterated  at  its  ca-cal  end  before  perfora- 
tion occurs,  as  is  claimed  by  some  writers,  is  shown 
by  such  cases.     The  pus  may  burrow  and  appear 
in  the  lumbar  region,  or  it  may  pass  down  and 
appear  in  the  peritoneum  and  form  a  peri-rectal 
abscess.      A  more  favorable  event  is,  when  the 
abscess  perforates  into  a  neighboring  viscus— the 
colon,  the  caecum,  the  rectum  or  the  bladder.     In 
a  recent  report  of  a  uabe  in  a  French  Journal,  m 
which  the  abscess  perforated  into  the  bowel,  tiie 
characteristic  oval  enterolith  was  found  with  the 
discharged  pus  and  fseces.     Perforation  into  tb- 
bladder  is  less  common.    At  the  Montreal  General 
Hospital,  in  the  Summer  session  of  1882,  IJectun'd 
upon  two  cases  in  which  this  event  occurred  with 


■,ure.      It  is   most 
iliac  fossa,  and  is 
i'hen  the  appendix 
[uembrane,  or  it  is 
e  appendix  (which 
irtial  serous  cover- 
jccur  with  the  £or- 
thin  the  pelvis  in 
ligament ;  in  ano- 
n  the  sacrum,  the 
;  left  of  the  middle 
le  abscess  was  high 
the  psoas  muscle, 
nt  stress  has  been 
local  inflammatory 
ies  the  graver  man- 
take  place  at  this 
ce  of  an  obliterated 
oid  thickening  and 
urrounding    tissue, 
with  abscess  forma- 
riable.    It  is  within 
physician  to  have 
ji  the  neighborhood 
pen  spontaneously, 
small  fragments  of 
ipen  communication 
ises  I  saw  with  my 
:er,   of   Dundas,   in 
cases  made  a  good 
ich  more  extensive 
ion  in  several  places 
),  succumbed  to  sep- 
bhe  appendix  is  not 
end  before  perfora- 
ne  writers,  is  shown 
burrow  and  appear 
lay  pass  down  and 
1  form  a  peri-rectal 
event   is,   when  the 
iboring  viscus — the 
or  the  bladder.     1  ii 
French  Journal,  in 
into  the  bowel,  the 
was  found  with  ihv 
Perforation  into  t!i ' 
le  Montreal  General 
nof  1882,  IJectuivd 
event  occurred  with 


i-ecovery.     I  met  with  a  fiurious  sequel  in  a  case 
of  peri-cffical  abscess   which   perforated   into  the 
bowels.     The  patient  had  for  some  years  aftor 
and  may  s^lll  have  for  aught  I  know,  persistent 
enlargement  of  the  right  leg,  due,  undoubtedly,  to 
chrome  venous  stasis  consequent  upon  the  narrow- 
ing of,  or  perhaps  the  obliteration,  of  some  of  the 
large  veins  in  the  pelvis.     A  third  and  almost 
necessarily  fatal  mode  of  termination,  is  when  the 
local  circumscribed  abscess  perforates  the  perito- 
neum, setting  up  a  diffuse,  virulent   and  septic 
mflammation. 

I  have  never  yet  seen  instances  of  perforative 
appendicitis  in  which  there  were  not  attempts  made 
to  limit  the  inflammation.     Even  when  the  appen- 
dix has  been  free  in  the  peritoneum,  walls  circum- 
scribing the  abscess  arr       rmed  by  the  adherent 
mesentery,  retro-peritoneum  and  intestinal  wall 
Symptoms   of  perforative  appendicitis  are  fairly 
well  defined.     A  number  of  cases  begin  with  in- 
testinal trouble,  constipation  or  pain  in  the  ilio- 
caecal  region,  lasting  for  a  variable  lime.     A  mo-e 
characteristic   mode  of  onset  is  a  sudden,  sharp 
pam  in  the  right  iliac  fossa.  This  may  be  followed 
by  collapse  symptoms,  or  more  usually  by  an  ag- 
gravation of   the   intestinal   disturbance.      It   is 
worth  noting,  that  strain,  such  as  sudden  lifting 
or  jumping,  may  be  followed   by  an  acute  pain 
and   may,    apparently,    be   the    starting-point   of 
appendicitis.     The  local  symptoms  are  rarely  as 
well  marked  as  in  typhlitis    Tenderness  is  usually 
present ;  there  may  be  fullness,  or  even  induration 
but  in  my  experience,  these  signs  are  more  fre- 
quently ,  absent.      The  leg  is  usually  drawn  up 
thereby  relaxing  the  psoas  m  uscle.     Irritability  of 
the  bladder,   as  shown  by  frequent  micturition 
not  infrequently  occurs.     The  fever  is  moderate' 
the  tongue  is  furred,  but  constipation  is  not  so' 
constant  a  feature  ac  in  stercoral  typhlitis      Ab- 
dominal aistention  (tympanites)  comes  on  early 
and  may  interfere  with  proper  examination.     A 
rectal  examination  may  indicate  fullness  towards 
tnc  roof  of  the  pelvis,  but  unless  the  whole  hand 
IS  used,  the  ordinary  digital  exploration  is  practi- 
cally worthless.     Practice  on   the  cadaver,   with 
the  pelvis  exposed,  shows  how  futile  is  the  attempt 
to  reach,  even  with  the  longest  finger,  those  higher 
portions  of  the  pelvis  which  the  peri-aecal  inflam- 
_mat,on   usually   afiects.      Increasing  tympanites 


diffuse  i    decubitus  of  the  pati( 
tutional    toms.     Cases  occur  i 
peritoni    accurately  determine 
peritoni    presents  the  picture 
the  abf     has  started  from  soi; 
small  in        Treatment  of  per 
abdomii    disease  has  made  g 
saw,  wi     few  years,  and  the 
tion  of  1     Parker  has  now  beci 
abdoniii    but  a  most  success 
board-li     stated,  there  are  m 
In  a      recovery,   even  whe 
sudden      occurred.     We  all  h 
not  the     *^*oks  of  this  disease 
sion  of  i    P®ar   and   the   patie 
As  I  ha    n^edical  treatment  i 
adhesioi    spoken  of  in  typhlit; 
in  perso    almost  always  to  b 
localized   constipation,   large 
possible     ^"   *h6   early  stage 
local  ab!   would  hesitate  to  er 
sympton   which  moves  the  bo 
forated  ;  ^'^oe  of  the  peristals; 
mischief    when  gen'^ral  peritoi 
tion,  tha  ^'his  method  of  trea 
onset  of    rational.     A  concer 
duration]  ^^^'^^  depletion  of  tl 
also  its  €  '^^'num  to  ca?cum,  a 


vation  of 
in  these 
region,  c 
ically  inf 
In  inf 
appendij 
all  the  s 
den  agon 
gastro-in 
days, 
fact,  tha 
present  j 
are  more 
nary  typ 
also  less  j 
portion  ol 
diagnosis 
of  onset, 
vious  his 
of  hernia 
rence  of  f 


interstitial  oedema 
which,  chiefly,  th. 
in  the  early  stages 
should  be  directed  t< 
tory  process,  and  fa^ 
riera   which   nature 


^1 


i^ecovei;;.,  I  met  with  a  fiurious  sequel  in  a  case 
of  peri-cjEcal  abscess  which  perforated  into  the 
bowels.  The  patient  had  for  some  years  after, 
and  may  still  have  for  aught  I  know,  persistent 
enlargement  of  the  right  leg,  due,  undoubtedly,  to 
chronic  venous  stasis  consequent  upon  the  narrow- 
ing of,  or  perhaps  the  obliteration,  of  some  of  the 
large  veins  in  the  pelvis.  A  third  and  almost 
necessarily  fatal  mode  of  termination,  is  when  the 
local  circumscribed  abscess  perforates  the  perito- 
neum, setting  up  a  diffuse,  virulent  and  septic 
inflammation. 

I  have  never  yet  seen  instances  of  perforative 
appendicitis  in  which  there  were  not  attempts  made 
to  limit  the  inflammation.     Even  when  the  appen- 
dix has  been  free  in  the  peritoneum,  walls  circum- 
scribing the  abscess  are  formed  by  the  adherent 
mesentery,  retro-peritoneum  and   intestinal  wall. 
Symptoms   of  perforative  appendicitis  are  fairly 
well  defined.     A  number  of  cases  begin  with  in- 
testinal trouble,  constipation  or  pain  in  the  ilio- 
cjfical  region,  lasting  for  a  variable  time.     A  more 
characteristic   mode  of  onset  is  a  sudden,  sharp 
pain  in  the  right  iliac  fossa.  This  may  be  followed 
by  collapse  symptoms,  or  more  usually  by  an  ag- 
gravation of   the   intestinal   disturbance.      It   is 
worth  noting,  that  strain,  such  as  sudden  lifting 
or  jumping,  may  be  followed   by  an  acute  pain, 
and   may,    apparently,    be   the    starting-point   of 
appendicitis.     The  local  symptoms  are  rarely  as 
well  marked  as  in  typhlitis    Tenderness  is  usually 
present ;  there  may  be  fullness,  or  even  induration, 
but  in  my  experience,  these  signs  are  more  fre- 
quently absent.      The  leg  is  usually  drawn  up, 
thereby  relaxing  the  psoas  muscle.     Irritability  of 
the  bladder,    as  shown   by  frequent  micturition, 
not  infrequently  occurs.     The  fever  is  moderate  ; 
the  tongue  is  furred,  but  constipation  is  not  so 
I  constant  a  feature  as  in  stercoral  typhlitis.     Ab- 
dominal distention  (tympanites)  conies  on  early, 
land  may  interfere  with  proper  examination.     A 
jrectal  examination  may  indicate  fullness  towards 
jthe  roof  of  the  pelvis,  but  unless  the  whole  hand 
|s  used,  the  ordinary  digital  exploration  is  practi- 
Pally  worthless.     Tr,M,ctice  on   the  cadaver,   with 
^he  pelvis  exposec,  niiows  how  futile  is  the  attempt 
-  rnach,  even  with  the  longest  finger,  those  higher 
ortions  of  the  pelvis  which  the  peri-ciecal  inflani- 
Qation   usually   affects.      Increasing  tympanites. 


diffuse  tenderness  on  paljiaii,,,!,  aggravated  consti- 
tutional symptoms,  indi.;,to  the  spread  of  the 
peritonitis.  It  must  not  i,,.  forgotten  that  the 
peritonitis  may  be  limited  i,,  the  lower  portion  of 

the  abdomen,  even  conii I  to  the  coils  of  the 

small  intestines  situated  uithin  the  pelvis.  Such 
abdominal  distention  may  i,,.  extremely  slight.  I 
saw,  with  Dr.  Musser.  last  year,  a  case  of  perfora- 
tion of  the  appendix  with  ji..iitonitis,  in  which  the 
abdominal  walls  were  flat  and  presented  a  hard, 
board-like  resistance  to  palpation. 

In  a  considerable  majorify  of  cases,  I  think  the 
sudden  on:et  with  sharp' intense  pain,  indicate.s, 
not  the  perforation  of  the  appendix,  but  the  exten- 
sion of  an  already  existin-  inflammatory  proces.^^. 
As  I  have  stated,  extensive  ulceration,  distention, 
adhesion  and  obliteration  of  the  tube,  may  occur 
in  persons  in  whose  history  there  is  no  account  of 
localized  abdominal  inflaniniation.     It  is  not  im- 
possible that  ulceration,  loading  to  perforation  and 
local  abscess,  nniy  occur  without  exciting  severe 
symptoms.     I  have  so  often  seen,  about  the  per- 
forated appendix,  signs  of  chronic  inflammatory 
mischief  indicated  by  fihr.tiis  hands  and  pigmenta- 
tion, that  the  process  has  certainly  ante-dated  the 
onset  of  the  acute  fatal  illness  of  only  a  few  days 
duration.      Marked  tendency  to  recurrence  finds 
also  its  explanation  here,  in  the  temporary  aggra- 
vation of  the  condition.  Siu-oonshavereneatedly, 
in  these  cases  of  recurring  attacks  in  the  peri-ca?cal 
region,  cut  down  and  reniowd  an  adherent,  chron- 
ically inflamed  and  even  perforated  appendix 

In  many  instances  tlie  diagnosis  of  perforated 
appendix  presents  great  (iifliculties.     Perhaps,  of 
all  the  .symptoms,  the  most  important  is  the  sud- 
den agonizing  pain  occurrini.'  either  at  first,  or  after 
gastro-intestinal   .symptoms  have  lasted  for  some  ^ 
days.     Its  importance  may  he  gathered  from  the 
fact,  that  of  237  cases  analyzed  by  Fitz,  it  was 
present  in  210.      Abdomin/ii  pain  and  distention 
are  more  marked,  and  ocenr  earlier  than  in  ordr 
nary  typhlitis.      Induration  in  tho  iliac  fossa  i.- 
also  less  common  ;  indeed,  a  very  considerable  pro 
portion  of  the  cases  picscnt  no  local  tumor.     The 
diagnosis  in  such  cases  rests  largely  upon  the  mode 
of  onset,  the  development  of  symptoms,  the  pre- 
vious history  of  the  patient,  the  absence  of  signs 
of  hernia  or  of  internal  strangulation.     The  occur- 
rence of  frequent  micturition  and  the  characteristic 


'f 


^'i'. 


decubitus  of  the  patiint,  are  highly  suggestive  symp- 
t(jins.  Cases  occur  in  which  it  seems  impossible  to 
accurately  determine  the  condition,  and  the  patient 
presents  the  picture  of  general  peritonitis,  which 
lias  started  from  some  unknown  locality. 

Treatment  of  peri  csecal  abscess  from  appendix 
disease  lias  made  great  progress  within  the  past 
few  years,  and  the  operation  devised  by  Willard 
Parker  has  now  become,  not  only  a  very  frequent, 
but  a  most  successful   oiie.     As  I  have  already 
stated,  there  are  many  instances  of  spontaneous 
lecovery,  even  when  extensive   suppuration   has 
occurred.     We  all  have  seen,  in  the  recurring  at- 
tacks of  this  disease,  the  gravest  symptoms  disap- 
pear and   the  patient   rapidly   convalesce.     The 
medical  treatment  is  much   the  same  as'  I   have 
spoken  of  in  typhlitis.     Opium,  in  some  form,  has 
almost  always  to  b^  used  to   relieve  pain.     For 
constipation,  large  injections  may  be  employed. 
In   the   early  stage;   I    never   use  purgatives,     I^ 
would  hesitate  to  employ  even  a  saline  cathartic, 
which  moves  the  bosvels  with  very  little  disturb- 
ance of  the  peristaHs.    Not  that  I  would  hesitate 
when  ceneral  peritonitis  is  established,  as  I  believe 
this  method  of  treatment  to  be  in  a  high  degree 
rational.     A  concentrated  saline  purge  produces 
local  depletion  of  t'.e  intestinal  vessels  from  duo- 
denum to  ciEcum,  aad  removes  in  great  part  the 
interstitial   oedema   of   the    intestinal    wall   upon 
which,    chiefly,    th.J    paralysis    depends.       But, 
in  the  early  stage^l  of  tt^ffthaflTection,  our  means 
should  be  directed  tt^wards  limiting  the  inflamma- 
;  tory  process,  and  fa'«|oring  those  conservative  bar- 
riers which   nature!  invariably   sets   up   against 


extending  inflammatio]^.  I  have  been  so  much 
impressed  with  the  fact,  that  in  these  cases  the 
dangerous  symptoms  seem  to  originate  by  the 
extension  of  the  disease  from  a  localized  peri-csecal 
abscess — the  walls  of  which  may  be  in  part  mesen- 
teric, or,  as  I  have  seen,  intestinal — that  I  dread 
the  disturbing  influence  of  purges.  The  indica- 
tions for  surgical  interference  are  not  always 
clear ;  but  my  experience  has  taught  me  that  the 
abdomen  is  much  more  frequently  left  untouched 
than  it  should  be,  and  that  an  operation  is  too 
often  deferred  until  practically  useless.  Local 
indications  may  be  very  positive,  particularly  when 
the  perforated  appendix  lies  behind  the  peritoneum, 
in  the  iliac  fossa  spine  above  Poupart's  ligament. 
But  when  the  abscess  is  high  on  the  psoas 
muscle,  or  lies  within  the  brim  of  the  pelvis,  or 
far  over  towards  the  middle  line,  these  symp- 
toms are  absent,  and  in  such  cases,  from  the  gene- 
ral condition  alone,  the  indications  for  operation 
must  be  gathered.  We  may  say,  as  a  general  rule, 
that  in  young  persons,  in  whom  the  attack  has  set 
in  with  severe  pain  in  the  right  iliac  fossa  (whe- 
ther preceded  or  not  by  previous  digestive  disturb- 
ance), and  in  whom  the  constitutional  symptoms, 
as  shown  by  rapid  pulse,  fever  and  coated  tongue, 
indicate  a  serious  lesion — when  tympanites  and 
abdominal  tenderness  exist,  it  is  better  in  these 
days  of  safe  laparotomy  to  give  the  patient  the 
benefit  of  any  diagnostic  doubt,  even  without  the 
existence  of  local  tumor,  and  to  explore  thoroughly 
the  peri-csecal  region.  Still  more  urgent  would 
such  indications  be,  if  the  patient  had  had  pre- 
vious, though  less  severe  attacks. 


4 


, [int,  are  highly  suggestive  symp- 
n  which  it  seems  impossible  to 
I  the  condition,  and  the  patient 
,  of  general  peritonitis,  which 
le  unknown  locality. 
'  csecal  abscess  from  appendix 
(•eat  progress  within  the  past 
'operation  devised  by  Willard 
(i»nie,  not  only  a  very  frequent, 
i'ul  one.  As  I  have  already 
iiny  instances  of  spontaneous 
in  extensive  suppuration  has 
lave  seen,  in  the  recurring  at- 
j.,  the  gravest  symptoms  disap- 
;  tnt  rapidly  convalesce.  The 
f:;8  much  the  same  as'  I  have 
\m.     Opium,  in  some  form,  has 

;?  used  to  relieve  pain.     For 

1>.   .      ■  ,  ,        . 

'injections  may  be  employed. 

f  I   never  use  purgatives.     I 
|aploy  even  a  saline  cathartic, 
flv^els  with  very  little  disturb- 
Is.    Not  that  I  would  hesitate 
liitis  is  established,  as  I  believe 
liment  to  be  in  a  high  degree 
'ftrated  saline  purge  produces 
,e  intestinal  vessels  from  duo- 
d  removes  in  great  part  the 
of   the   intestinal    wall  upon 
paralysis    depends.       But, 
of  tl^9ik.affection,  our  means 
|wards  limiting  the  inflamma- 
oring  those  conservative  bar- 
invariably   sets   up   against 


extending  inflammatioy.  I  have  been  so  much 
impressed  with  the  fact,  that  in  these  cases  the 
dangerous  symptoms  seem  to  originate  by  the 
extension  of  the  disease  from  a  localized  peri-csecal 
abscess — the  walls  of  which  may  be  in  part  mesen- 
teric, or,  as  I  have  seen,  intestinal — that  I  dread 
the  disturbing  influence  of  purges.  The  indica- 
tions for  surgical  interference  are  not  always 
clear ;  but  my  experience  has  taught  me  that  the 
abdomen  is  much  more  frequently  left  untouched 
than  it  should  be,  and  that  an  operation  is  too 
often  deferred  until  practically  useless.  Local 
indications  may  be  very  positive,  particularly  when 
the  perforated  appendix  lies  behind  the  peritoneum, 
in  the  iliac  fossa  spine  above  Poupart's  ligament. 
But  when  the  abscess  is  high  on  the  psoas 
muscle,  or  lies  within  the  brim  of  the  pelvis,  or 
far  over  towards  the  middle  line,  these  symp- 
toms are  absent,  and  in  such  cases,  from  the  gene- 
ral condition  alone,  the  indications  for  operation 
must  be  gathered.  We  may  say,  as  a  general  rule, 
that  in  young  persons,  in  whom  the  attack  has  set 
in  with  severe  pain  in  the  right  iliac  fossa  (whe- 
ther preceded  or  not  by  previous  digestive  disturb- 
ance), and  in  whom  the  constitutional  symptoms, 
as  shown  by  rapid  pulse,  fever  and  coated  tongue, 
indicate  a  serious  lesion — when  tympanites  and 
abdominal  tenderness  exist,  it  is  better  in  these 
days  of  safe  laparotomy  to  give  the  patient  the 
benefit  of  any  diagnostic  doubt,  even  without  the 
existence  of  local  tumor,  and  to  explore  thoroughly 
the  peri-csecal  region.  Still  more  urgent  would 
such  indications  be,  if  the  patient  had  had  pre- 
vious, though  less  severe  attacks. 


Lx 


XX  V III 


IX 


PUERPERAL  ANEMIA,  AND  ITS  TREAT 
MENT  WITPT  ARSENIC. 

UV   WILLIAM  08LKR,  M.U 

cases,  amrinWperTif?  Vf 'rT.  t'^"'^^^'^  «""ilar 

appeared  abounre\amftimfm^^ 
interest  in  this  subject  '  '  '''''"'^'^  ''^  ^*««"1' 

.  The  importanoe  of  this  etiolomcal  fiotor ;» 
•■lous  anemia  is  shown  bytlie  tSmnfnf         r™' 
observations  collected  bV EiclXopstlh       '''*^-°"'^ 
in  twenty-nine  cases  d^Lt     I  ■     '  *^'^  synii^tonis 
nreL'Danr^.    -.f  t^        t^eveloped  m  connection  with 

who„  «.  ccair-riJiy^  P^a^l-ol 


Sk 


11 


!  ii 


1 

f 

4 

! 

i 

"■  ■    i  .  ' 

^! 

i  t 

i 

J 

■ 

^nt,  are  highly  8Ug 
^n  which  it  seema 
I  the  condition,  ai 
of  general  peril 
le  unknown  loca 
I  csecal  abscess  f r 
peat  progress  wi 
operation  devisei 
;>nie,  not  only  a  v 
f'ul   one.     As  I 
finy  instances  of 
a  extensive   sup 
ave  seen,  in  the 
the  gravest  syn 
int   rapidly   con^ 
ta  much   the  san 
Is.     Opium,  in  sc 
|i  used  to  reiiev 
injections  may 
I   never  use  p 
I  (>ploy  even  a  sali 
(vels  with  very  ] 
I   8.    Not  that  I  M 
litis  is  establishec 
bment  to  be  in,£ 
itrated  saline  pu 
1,6  intestinal  vesa 
ftd  removes  in  gi 
*of   the   intestim 
|)    paralysis    dep 
of  tl?si».affectioi 
iwards  limiting  1 
'oring  those  com 
invariably   sett 


these  cases,  three  recovered ;  of  one,  I  aiu  doubtful, 
as  the  patient  removed  to  a  distance  and  has  not 
since  been  heard  from;  the  fifth  case  T  have  here 
given  in  full,  as  illnstvative  of  certain  important 
points   in   connection  Avith  the  treatment  of  this 

coudition.  ,     ■  .    , 

Amelia  T.,  a^ed  thirty-five,  domestic,  was  admitted 
to  the  medical  wards  of  Philadeli)hia  Hospital  on 
25th  February,  1888.     Nothing'  of  note  in  family 
or  previous  personal  history.    In  October,  1887,  she 
was  confined  of  her  fourth  child  — easy  delivery. 
She  was  well  through  her  pregnancy,  but  in  last 
month  had  suffered  with  bleeding  piles.     She  was 
up  and  about  two  weeks  after  delivery,  nursed  the 
baby,  but  was  very  pale  and  weak.     She  was  dis- 
charged in  about 'six  weeks.     She  never  regained 
color  after  her  confinement  and  had  many  spells  of 
fainting,  once  or  twice  having  fallen  in  the  street. 
After  January  1st  this  condition  grew  worse,  and 
diarrh-ea  set  in.     When  admitted  she  was  in  a  con- 
dition of  profound  aiia'inia,  and  had  severe  diarrhrea 
with  irregular  fever.    She  was  placed  on  Tr.  perchl. 
Fe,  gtt.  20,  t.i.d.     She   remained  in  bed  and  had 
not  im]i.'oved ;  and  when  I  saw  her  first  on  ITtli 
A]-.i-il  she  was  in  the  following  condition:  — 

Profound  anaemia;  face  and  general  cutaneous 
surface  has  slight  subicteroid  hue;  fat  is  fairly 
well  retained,  though  the  arms  look  thin,  conjunc- 
tiva^ pearly,  tongue  extremely  blanched.  She  is 
unable  to  sit  up  on  account  of  the  fainting.  Has 
three  or  four  movements  of  the  bowels  daily.  Pulse 
120°,  small,  jerky.  Periiiheral  veins  not  very  full. 
Apex  beat  of'  heart  at  fourth  interspace ;  visible  pul- 
sation in  sidx'laviaus  and  carotids.  There  is  a  rougli 
thrill  with  first  sound.  Cardiac  dulness  from  lower 
border  third  rib.    On  auscultation  both  sounds  heard 


•A 


at  apex  with  much  edio;  loud  systolic^  innrmur, 
propagated  to  axilla  ;  also  heard  very  plainly  idong 
left  sternal  border.  Distinct  systolic;  inurnur  at 
aortic  cartilage.  Second  sound  much  accentu.'ited. 
Lungs  normal.  No  enlargement  of  sideeu  or  liver. 
Tenderness  on  ])ressure  over  alxlomen.  (ilands 
are  not  enlarged.  Fever  range  of  2  or  :i  degreea 
daily.  Blood  very  watery;  red  corpuscles  per 
cu.mm.  1,170,000;  percentage  white  to  red,  1  :  484; 
color  by  Gowers'  ha'moglobniometer,  about  lo-18% ; 
corpuscles  extremely  irregular  in  size  and  shape; 
considerable  proportion  of  larger  ones  are  oval. 
There  are  many  microcytes.  Several  nucleated  red 
blood  corpuscles  were  seen. 

SheAvas  ordered  Fowler's  solution,  five  minims 
t.i.d.  for  a  Aveek,  and  then  to  increase  one  drop  each 
(lav  until  ten  minims  were  reached  ;  opium  supposi- 
tories for  the  diarrhoea,  and  in  a  few  days  enemata 
of  dried  blood.  Blood  count  on  April  L'Gtli,  1,480,000 ; 
color  percentage,  L'O.  She  took  the  arsenic  well,' 
began  to  improve  in  color,  and  on  May  10th  blood 
coimt  by  Dr.  Henry  Avas  as  folloAvs :  Red  corn 
2,800,000;  haMm)gh)bin,  40%.  ^  ' 

Patient  improved  rapidly  through  the  simimer,  the 
diarrhoea  stoi)ped  and  she  gained  greatly  in  Aveight. 
When  I  Avent  on  duty  Sei)t.  Cm\  1  did  not  recognize 
the  patient,  now  a  large  robust-looking  Avoman  Avith 
excellent  color.    The  apex  systolic  nuirmur  i)ersists. 

We  have  in  this  case  a 'history  very  similar  to 
that  Avhich  is  met  Avith  in  the  majority  of  instances 
of  post-i)artum  anemia.  It  is  interesting  to  note 
that  the  patient,  prior  to  delivery,  had  suffered  Avith 
hemorrhoids,  and  had  lost  from  this  source  consid- 
erable blood.  She  never  regained  her  color  after 
confinement,  but  remained  very  pale,  and  after  dis- 
charge from  the  hospital  she   had  many  fainting 


'■1 
If 


m 


If 


hS^^'     ^"^de"  int^'stmal  hemorrhage  in  an  apparently 
^^^Ithy  person,  which  tends  to  recur  and  produce  a  pro 

»  Am^ir'  ^I'^^'^^f^'  Awl,  May,  and  June,  1887. 
>  rS'^'^iir'""™,^'  ■      '-=  ^^dical  Sciences.  1888,  i. 
Canada  Me      al  and  Surgical  Journal,  March,    887 


,^nt,  are  highly  sug 
,n  which  it  seems 
i  the  condition,  ar 
;j  of  general  peril 
:,ie  unknown  loca 
i.  cBBcal  abscess  fr 
J-eat  progress  wi 
jpperation  devisei 
|)nie,  not  only  a  \ 
|:ul   one.     As  I 
sjjiny  instances  of 
|n  extensive  sup 
ave  seen,  in  the 
,  the  gravest  syn 
mt    rapidly   con> 
a  much   the  san 
8.     Opium,  in  sc 
'.  used  to  reliev 
injections  may 
I   never  use  p 
1  oploy  e   _"..  i«i  sail 
wrels  with  very  1 
18.    Not  that  I  M» 
litis  is  establishec 
braent  to  be  in  t 
!  trated  saline  pu 
,e  intestinal  vess 
ad  removes  in  gi 
)  of   the   intestinf 
5    paralysis    dep 
of  th^affectioi 
■  iwards  limiting  1 
'oring  those  com 
'  invariably   sets 


spells.  The  coiiditioii  in  whioh  I  i'<'"ii<l  hcv  was 
oxtremt'ly  gruve.  She  rould  not  sit  up  in  bed  with- 
out laintiuK;  and  she  had  constant  vomiting,  with 
uncontroUabU"  diavrluva.  I  did  lu.t  fxpcft  her  to 
rcoover.  The  blood  condition  was  typical  as  rc- 
i^Mvds  the  appcaranco  of  the  corpuscles.  The  per- 
i'eHta<,'e  of  coloviiiK  matter  was,  however,  reduced 
pioportioually  to  the  corpuscles.  Indeed,  the  indiv- 
idual value  of  the  corpuscles  in  Ineinoglobin  was 
rather  below  par.  Tn  the  majority  of  instances  o1 
iiernicicms  aiueiuia  the  reverse  liohls  good. 

The  case  illustrates  an  important  point  m  tlie 
treatment  of  profound  anuMuia.  This  patient  had 
received  twenty  drops  of  the  tincture  of  ])erchl'.ride 
of  iron  three  times  a  day,  from  Feb.  '2»t\i  to  Apr 
17th.  Her  diet  had  been  carefully  regulated,  and 
every  possible  means  employed  to  check  the  diar- 
rh(i?a  and  vomiting.  .  ,     ^ 

Fowler's  solution  was  begun  with  hve  minim 
doses  three  times  a  day,  and  for  a,  time  was  well 
borne.  The  dose  was  gradually  increased,  and  the 
improvement  was  rapid.  <  >n  several  occasions  the 
sickness  of  the  stomacli  was  aggravated,  and  the 
medicine  was  interrupted  for  a  week. 

By  the  19th  of  May  she  was  able  to  sit  up  in  bed, 
her  appetite  began  to  improve,  the  corpuscles  had 
more  than  doubled  in  number  per  cubic  millimetre 
the  hfemoglobiii  had  risen  from  15  to  40%.  Rectal 
injections  of  dried  blood  were,  for  a  time,  employed, 
biit  had  to  be  stopped  on  account  of  the  irritation 
they  produced.  .     ^  m 

I  did  not  see  this  patient  from  the  end  ot  iMay 
until  I  went  on  duty  Sei)t.  .Srd,  at  which  time  I  did 
not  recognize  her.  She  had  grown  stout,  her  color 
was  excellent,  and  she  looked  in  robust  health.  1  he 
patient's  recovery  may  be  attributed  to  the  arsenic. 


/  X 


fdiinil  lior  was 
,  lip  in  l)f(l  witli- 
;  vomiting,  \vitli 
t  t'Xpct't  her  to 
)  typical  ns  vc- 
scl«''S.  TliP  por- 
;)W('V('T,  rediii'od 
iidt't'd,  tlu'  indiv- 
ui'iuogloliiii  was 

of  instances  ol 
is  good. 

,nt  point  in  tlie 
Miis  patient  had 
IV.  ot  ])eri!hl''ride 
'b.  iJoth  to  Apr. 
[y  regulated,  ami 

check  the  diar- 

vith  five  minim 
ii,  time  was  well 
icreased,  and  the 
•al  occasions  the 
ravated,  and  the 
A. 

3  to  sit  up  in  bed, 
e  corpuscles  had 
cubic  millinu'tie, 

to  40%-  Kt^ct:il 
I  time,  employed, 
of  the  irritation 

the  end  of  IMay 
which  time  I  did 
[1  stout,  her  color 
bust  health.  The 
ed  to  the  arsenir, 


and  1  believe  that  if  the  iron  had  been  continued 
slie  would  have  failed  i)rogressividy,  as  she  did  dur- 
ing the  six  or  seven  weeks  in  whidi  it  had  Ixsen 
administered. 

This  is  by  no  means  a  unique  liistory.  To  Kram- 
well,  of  Ediidiurgli,  tlie  profession  is  "indebted  for 
pointing  out  the  almost  sjiecitic  action  of  this  drug 
in  certain  cases  of  pernicious  aiuemia. 

Tlie  statistics  collected  by  Tadl-y  i  a  few  years 
ago  show  forty-eight  cases  treated  without  arsenic, 
of  whicli  forty-two  died.  Of  twenty-two  cases 
treated  witli  arsenic  sixteen  recovered,  four  died, 
and  two  improved. 

Within  the  past  few  years,  numerous  observations 
liave  sliown  tlu^  powerful  effect  of  arsenic  in  certain 
cases.  Unfortunately,  we  do  not  yet  fully  under- 
stand why,  in  some  instances,  the  drug  siiould  be 
well  borne  and  prove  successful,  while  in  others 
the  patient  continues  in  the  progressively  downward 
course. 

That  the  cases  which  we  group  as  pernicious 
anaemia  are  very  varied  is  now  recognized  by  all 
writers  on  tlie  subject.  It  is  not  to  be  expected 
that  when  the  gastric  tubules  are  atrophied  arsenic 
can  be  curative.  We  need  a  careful  study  of  those 
instances  in  whicli  the  drug  has  jiroved  successful 
and  of  those  in  which  it  has  failed. 

To  judge  from  therapeutic  test  alone  there  must 
be  a  very  deep-seated  difference  between  the  two 
(dasses. 

I  know  of  nothing  more  remarkable  in  practical 
therapeutics,  nothing  so  resembling  specific  action 
(unless  we  except  iron  in  chlorosis  and  quinine  in 
agiie)  than  the  rapid  recovery  of  profound  aneemia 
under  tliis  drug.   As  a  rule  it  is  well  borne ;  and  should 

'  Lancet.  1883.  il. 


i  if 


'     I  I 


'    M^! 


til 


^j 


il 


uZT^'     ^"d<ien  intestinal  hemorrhage  in  an  apparentlv 
healthyperson,  which  tends  to  recur  Ind  produceTpro^ 

I  Archives  Genorales,  April,  May,  and  Tune,  1887  ~ 

Canada  Medical  and  Surgical  Journal,  March,    887 


m 


i^nt,ar«  highly  8Ug 
n  whioli  it  Heema 
tlio  condition,  '^t 
if  general  peril 
I©  unknown  loca 
uecal  ahscess  fr 
oat  progreHs  wi 
(tperation  devisei 
»nie,  not  only  a  v 
ul   one.     Ab   I 
iiiy  instances  o£ 
II   extensive   sup 
ave  seen,  in  the 
the  gravest  syn 
mt    rapidly    con> 
8  much   the  san 
a.     Opium,  in  sc 
used  to  reliev 
injections  may 
||i  I   never  use  p 
aploy  even  a  sali 
wels  with  very  1 
18.    Not  that  I  M 
litis  is  establishet 
bment  to  be  in  i 
trated  saline  pu 
.e  intestinal  vess 
ad  removes  in  gi 
hof   the   intestint 
)    paralysis    dep 
of  tli^affectioi 
iwards  limiting  I 
'oring  those  com 
'  invariably   sets 


a 


W  given,  as  liramwell  advises,  in  increuHing  doses, 
Ix'ginning  with  live  niiiiiniH,  anil  rising  gnulually 
to  twenty  or  thirty  three  times  a  day. 

I'lirtiness  ot'  the  eyelids,  (edema  above  th«  eye- 
brows, vomiting  or  diarrluea,  indicate  that  the  drug 
should  be  suspended  for  a  time,  or  the  dose  reduced. 
It  is  interesting  to  note  that  the  existence  of  vomit- 
ing or  diarrhoa  does  not,  however,  contraindicite 
the  emi)l()ynieut  of  the  medicine,  as  in  the  case 
here  reported.  These  symptoms  seemed  tf)  improve, 
for  a  time   at  least,  when  the   arsenic    was    first 

given. 

If  the  Fowler's  solution  disagrees,  arsenious 
acid  may  be  tried.  I  have  known  it  to  be  well 
borne  when  the  liquor  arsenicalis  disturbed  the 
stomach.  The  drug  may  be  given  hypodermically, 
but  in  these  instances  of  profound  anaemia  the 
tendency  to  hanuorrliage  is  so  marked  that  the 
punctures  may  become  hemorrhagic.  I  have  known 
considerable  subcutaneous  extravasation  follow  au 
iniection.  The  point  of  the  greatest  importance  is 
the  fact  that  the  medicine  must  be  given  in  increas- 
ing doses,  and  for  prolonged  periods. 

I  find  practitioners  express  great  surprise  when 
they  hear  of  doses  of  Fowler's  solution,  of  fifteen, 
twenty,  and  twenty-five  drops  three  times  a  day. 
There  is,  I  think,  but  one  rule  in  the  matter :  give 
the  drug  cautiously  until  physiological  effects  are 
produced.  The  tolerance  of  the  system  for  arsenic, 
IS  well  known.  I  havt',  never  seen  serious  conse- 
quences from  its  careful  administration.  Youii.u 
persons,  as  a  rule,  take  it  better  than  adults.  In 
an  instance  of  pernicious  amemia  which  I  reporteil 
a  few  years  ago,  the  patient  took  twenty  minims  oi 
Fowler's  solution  time  timcR  a  day  for/veeks,  with 
the  most  satisfact'-ry  le-.u't-s. 


/  X 


ncrciiHing  dosoH, 
rising  f»ia(luiilly 

al)ovc  tho  cyo- 
iti!  that  the  druj? 
he  (lo8e  re(hiCP(l. 
istenco  of  vonat- 
•,  contraiiidio  ite 

n»  in  the  case 
smed  to  improve, 
[•senic    was   first 


In  ixist-partiiiii  ca-seH  recovery  is  always  slow. 
It  may  he  many  months  before  [ierfect  health  is 
restored.  It  is  well  to  intermit  arsenic  tor  a  few 
weeks,  hut  the  dniK  should  [n-  ^\vn\  at  intervals 
for  many  months,  even  when  the  health  is  aj)- 
parently  re-established,  as  there  is  a  well-i'eeognized 
tendency  in  these  cases  to  relapse. 


i    S  .'-k.M 

m 


grees,  arsenious 
n  it  to  be  well 
is  disturbed  the 
hypodermically, 
nd  anaemia  the 
narked  that  the 
c.  I  have  known 
sation  follow  au 
'st  importance  is 
given  in  increas- 
Ls. 

it  surprise  when 
lution,  of  fifteen, 
ree  times  a  day. 
the  matter :  give 
Dgical  effects  art^ 
lystem  for  arsenic, 
fn  serious  eonsc- 
stration.  Youuf: 
than  adults.  In 
which  I  reported 
twenty  minims  of 
i,y  for^  weeks,  witli 


hZT'     ^"dde",  intestinal  hemorrhage  in  an  apparently 
healthy  person,  which  tends  to  recur  and  produce  a  pro 

»  Am-!i'"  H''"'"'''''f''/P"''  M''*^'  and  June,  1887.  ~ 

.  rf„  i  ''xT^^^™.'''  "'^'h"  Medical  Sciences,  1888,  i 
Canada  Medical  and  Surgical  Journal,  March,  i887 


1 

^ 

^   r'' 

1 

H- 

I 

1 

M 

'■ii- 

J 

l)nt,  are  highly  sug 
jH  which  it  seems 
,^  the  condition,  ar 
)  of  general  peril 
,16  unknown  loca 
I  csecal  abscess  f  r 
•eat  progress  wi 
.operation  devisei 
,>nie,  not  only  a  v 
:ul   one.     As   I 
iny  instances  of 
a  extensive   sup 
ave  seen,  in  the 
,  the  gravest  syn 
■nt    rapidly    com 
s  much  the  san 
s.     Opium,  in  sc 
^  used  to  reliev 
injections  may 

I    never  use  p 

oploy  even  a  sali 

(vels  with  very  1 

Is.    Not  that  I  M 

litis  is  establishec 

jiment  to  be  in  £ 

;  trated  saline  pu 

;  ,e  intestinal  vess 

^  ad  removes  in  gi 

)  of   the   intestinf 

J    paralysis    dep 

?    of  tl^»aflfectioi 

>wards  limiting  < 

'oring  those  com 

invariably   sets 


^?^XX/  X 


In 


ON   THE   DIAGNOSIS 

OF 

DUODENAL    ULCER. 

By  WILLIAM   OSLER,  M.D., 

PROFESSOR    OF   CUN.CA,,   MBmc.NE   l^   THE    UN.VERS. TV  OP   PENNSYLVANIA. 


Rtprintedfrom  The  Medical  Record,  A-ovemb,r  24.  1888. 

It  has  recently  been  suggested  by  Bucquoy'  that  the 
duodenal  is  to  be  distinguished  from' the  gastrk  ulcer  by 
certain  well-defined  clinical  characters  Dr  W  W 
Johnston,  of  Washington,  has  reported'  an  interesting 
case  which  seems  to  bear  out  this  author's  staSment 
I  have  expressed  myself  somewhat  sceptically  on  thS 
point,  although  one  of  the  nine  cases  which  formed  the 

Dr^Sl      ""^''''"i  ^T'^  ^^^  ^^g^^ded  during  hfe,  by 
Dr.  Palmer  Howard,  of  Montreal,  as  probably  duodenal 
on  rnuch  the  same  grounds  as  Bucquoy  lays  down  ' 

Physiologically,  the  portion  of  the  duodenum  above  the 
bile  papilla  belongs  to  the  stomach.  Peptic  diglst  on 
only  ceases  where  the  acid  chyme  is  neutralized  by  he 
bile.  When  we  consider  how  limited  is  this  region,  and 
how  close  to  the  pyloric  ring  many  gastric  ulcerf  Se  iJh 
not  surprising  that  difficulty  should  exist  in  the  dia^osi 

The  points  upon  which  Bucquoy  lays  the  greatesfstress 

Src=.'^'T'!f:i'  °^-  '^^  ^"°^^"^1  "'^^^'  ^'•^  ^^  follows  : 
h^fi  K        ^"dde\\"testinal  hemorrhage  in  an  apparently 
h^lthy  person,  which  tends  to  recur  Ind  produce  a  pro 

'  Archives  Genorales,  April,  May,  and  lune    1887 
Canada  Med.cal  and  Surgical  Journal,  March,  isS;. 


1  'f 


Ilk 


■?> 


:   *^ 

■ 

2 

found   ansemia.      Hemorrhage    from   the    stomach    may 
])recede  or  accompany  the  melcena. 

Second.  Pain  in  the  right  hypochondriac  region  com- 
ing on  late  ;  two  or  three  hours  after  eating. 

Third.  Ciastric  crises  of  extreme  violence ;  the  hem- 
orrhage being  more  ajjt  to  occur  about  the  time  of  these 
n.tt3.CiCS 

The  following  cases  are  of  interest  in  connection  with 
possible  existence  of  duodenal  ulcer. 

Case  I. — Dyspepsia.  Biematemesis  and  nicliena  m 
1870.  Repeated  attacks  during  the  past  eig/itcn  years, 
with  the  exception  of  the  three  years,  1877-1880,  J'te- 
quent  attacks  of  heniorr/iage  from  the  Ixmwls  iviihout  vom- 
iting; of  blood.     Sa'cre  gastralgia. 

Henry  C ,  upholsterer,  aged  forty,  was  brought  to 

the  Philadelphia  Hospital  by  the  ambulance,  on  January 
4,  1888,  in  a  condition  of  juofound  exhaustion.  'I'he 
next  morning  he  gave  the  following  account :  For  a 
month  he  had  had  diarrhoea,  and  on  several  occasions 
had  passed  blood  in  the  stool,  without  any  vomiting.  On 
the  night  of  January  ist,  he  vomited  nearly  two  quarts 
of  blood.  On  the  2d  he  remained  in  bed  very  much 
prostrated,  and  that  night  again  vomited  a  large  quantity 
of  blood,  "  half  a  basinful,"  he  said.  On  the  3d  he 
had  no  vomiting,  and  on  the  evening  of  the  4th,  when 
in  hospital,  he  vomited  three  or  four  times  and  brought 
up  clots  of  dark  granular  matter.  On  inspection,  the 
patient  was  found  to  be  profoundly  anaemic  and  unable 
to  sit  up  in  bed  without  fainting  ;  his  skin  was  like  ala- 
baster ;  pulse  130,  small;  respiration  20;  blood-count, 
950,000  r.c.  per  c.mm.     Haemoglobin,  twenty  per  cent. 

The  history  which  he  gave  was  remarkable.  He  had 
been  healthy  as  a  young  man,  with  the  exception  of  dys- 
pepsia. In  February,  1870,  he  had  a  hemorrhage  from 
the  stomach  and  brought  up,  he  says,  two  bowlfuls  ot 
blood,  and  also  passed  blood  in  the  stool.  During  the 
next  two  years  he  had  several  attacks,  and  suffered  con 
stantly  with  pains.  In  1873  he  nearly  died  of  hemor- 
rhage, and  during  the  next  four  years,  three  months  did 
not  pass  without  a  recurrence.  In  1877,  he  was  four 
weeks  in  tlie  Pennsylvania  Hospital,  having  ha*',  profuse 
hemorrhage  from  bowels  and  stomach.  He  returned  to 
France  after  this,  and  on  August  loth  had  bleeding  from 
the  bowels.     For  the  next  three  years  he  had  no  hem- 


action  with 


orrhage,  though  he  was  never  free  from  uneasy  sensations 
in  stomach,  and  at  times  had  attacks  of  severe  pain. 

In  1 88 1  the  haematemesis  recurred,  and  since  then  he 
has  had  repeated  attacks.  In  1883  he  was  in  the  hos- 
pital sixty-five  days;  lost  sixty-five  poimds  in  weight,  and 
was  believed  to  have  cancer  of  the  stomach.  From  this 
time  he  had  more  or  less  gastric  disturbance,  consisting  of 
pain  after  eating,  usually  delayed  for  several  hours  At 
intervals  of  a  few  weeks  there  would  occur  severe  gastric 
crises,  m  which  tlie  pain  would  be  agonizing  in  character 
shooting  from  the  stomach,  back,  and  sides ;  he  vomited 
sometimes  large  quantities  and  occasionally  had  attacks 
of  diarrhoea.  When  in  hospital,  in  1883,  he  was  taught 
to  wash  out  the  stomach  with  a  tube,  and  he  has  done  it 
ever  since,  at  intervals,  with  great  benefit.  He  remained 
under  observation  until  March  26th,  and  the  blood  con- 
dition was  carefully  studied,  with  the  following  results : 

January  5th,  r.b.c,  950,000  per  c.mm.;  6th,  770,400- 
7th,  1,053,000;  8th,  1,086,400;  9th,  1,175,000;  loth' 
1,179,000;  i2th,  816,400  (bleeding  the  night  before)- 
13th,  1,034,400;  15th,  916,320;  19th,  1,300,000. 

H  rom  this  time  the  rate  of  increase  was  rapid.  When 
he  left  the  hospital  the  blood-count  was  over  3,<;oo,ooo 
per  c.mm.  "^ 

On  January  14th  he  had  a  large  movement  of  the 
bowels  containing  blood,  but  there  was  no  vomiting 
I^rom  this  time  on  the  bleeding  ceased.  His  apnetite  be- 
came ravenous,  and  it  was  with  the  greatest  difficulty  that 
he  could  be  confined  to  proper  diet.  Examination  of  the 
abdomen  revealed  slight  distention;  no  tenderness-  no 
trace  of  tumor.  The  abdominal  walls  were  thick,  and  it 
was  difficult  to  outline  the  stomach,  the  gastric  tympany 
extending  a  hand's  breath  below  the  costal  margin.  The 
organ  appeared  to  be  slightly  enlarged;  liver  dulness 
normal ;  splenic  dulness  not  increased.  There  were  the 
usual  cardiac  and  arterial  phenomena  of  profound 
anaemia.  Throughout  the  month  of  February  the  im- 
provement was  very  rapid.  He  gained  in  weight ;  began 
to  have  a  little  color  and  had  no  gastric  distress,  even  after 
a  full  meal.  He  had  diarrhoea  at  times ;  three  or  four 
stools  in  a  day.  Early  in  March  he  was  .mxinus  to  "o  to 
work,  and  was  with  difficulty  kept  in  hospital.  He  had  no 
vomiting,,  and  stated  that  he  felt  perfectly  well  with  the 
exception  of    a  slight  weakness.     He    had    a    ravenous 


i 

ill 

:    3       21 

! 
1 

1 

!  ^ 

'   1    - 

J 

i 


■I 


1.1;        ';1 
'liEi  i:iiii:-k'itll 


If  I 


ir 


appetite,  and  I  repeatedly  had  to  warn  him  against  eating 
too  much.  He  returned  to  work  March  26th,  and 
through  the  spring  and  summer  remained  fairly  well. 

On  August  4th  the  hemorrhage  from  the  stomach  re- 
curred and  continued  four  days.  He  lost  much  blood 
and  grew  rapidly  weak.  In  the  course  of  a  week  he  re- 
turned to  work,  and  on  September  5  th  called  to  see  me 
at  my  office,  having  come  directly  from  the  workshop. 
He  was  profoundly  anaemic,  extremely  short  of  breath,  and 
could  scarcely  get  up  the  stairs.  I  or  nearly  a  week  he 
had  been  passing  blood  from  the  bowels,  without  vomit- 
ing. He  was  admitted  to  the  University  Hospital  Sep- 
tember 5th.  He  complained  of  slight  L^astric  distress,  but 
had  no  bleeding  until  the  20th,  when  1  vomited  nearly  a 
pint  of  blood,  dark  in  color,  mixed  with  food.  The  same 
evening  he  passed  large  quantities  from  the  bowels.  With 
the  exception  of  weakness  he  insisted  that  he  felt  well, 
and  was  always  asking  for  more  to  eat.  There  was  no 
further  vomiting  during  his  stay  in  hospital,  and  his  blood- 
count,  which  had  been  about  1,500,000  on  October  8th, 
rose  rapidly  to  nearly  3,000,000  per  c.mm.  He  gained 
seven  pounds  in  weight  within  a  month. 

On  the  8th  the  examination  of  the  abdomen  gave  re- 
sults as  follows  :  Somewhat  dilated;  uniformly  tympanic; 
no  tenderness ;  no  tumor  to  be  felt ;  obscure  sense  of  in- 
creased resistance  at  a  point  midway  between  the  navel 
and  right  costal  margin ;  liver  dulne&s  from  the  sixth  rib 
to  costal  margin. 

He  has  periods  of  freedom  from  abdominal  pain,  but 
not  of  long  dura  ion.  After  a  full  meal  he  is  at  first  com- 
fortable, but  in  three  or  four  hours  there  are  uneasy  sen- 
sations in  the  stomach,  often  positive  pains,  which  may 
become  severe.  When  the  stomach  is  empty  and  the  pain 
becomes  intense,  taking  food,  even  a  biscuit  or  half  a  glass 
of  milk,  will  give  relief.  As  stated,  there  is  no  epigastric 
tenderness,  and  he  always  locates  the  pain  along  a  line 
from  the  ensiform  cartilage  to  the  spine  of  the  left  ilium. 

Case  H. — From  1869  dyspepsia  and  occasional  attacks 
of  gastralgia.  In  1880  hcematemesis  and  mehena.  In 
1882  slight  melcEna  ivithout  vomiting.     Since  then  repeated 

attacks  'of  gastralgia. — A.  B ,  ag*  d  forty>  good  fam.ily 

history ;  was  delicate  as  a  lad,  but  after  the  age  of  four- 
teen enjoyed  the  average  health  with  the  exception  of 
dyspepsia,  to  which  he  was  liable,  and  he  would  at  times 


5 


nst  eating 
!6th,  and 
well. 

)mach  re- 
jch  blood 
eek  he  re- 
to  see  me 
workshop, 
ireath,  and 
a  week  he 
out  vomit- 
;pital  Sep- 
stress,  but 
d  nearly  a 
The  same 
:els.  With 
;  felt  well, 
;re  was  no 
his  blood- 
;tober  8th, 
He  gained 

n  gave  re- 
tympanic  ; 
ense  of  in- 
the  navel 
le  sixth  rib 

1  pain,  but 
t  first  com- 
ineasy  sen- 
ivhich  may 
nd  the  pain 
balf  a  glass 
3  epigastric 
long  a  line 
left  ilium. 
'fia/  attacks 
\elccna.  In 
\en  repeated 
food  family 
ige  of  four- 
tception  of 
lid  at  times 


regurgitate  food  without  discomfort  or  nausea.  In  1 869 
he  had  gastric  distress  sufficient  to  make  him  at  times 
press  hard  against  the  stomach  ;  no  nausea;  no  vomiting. 
With  the  exception  of  attacks  of  dyspepsia  he  remained 
well  until  September,  1876,  when  he  had  fever,  and,  dur- 
ing convalescence,  violent  attacks  of  gastralgia.  These 
occurred  sometimes  with  vomiting.  He  had  more  or  less 
gastric  distress  until  1879,  and  he  was  believed  at  this 
time  to  have  malarial  gastralgia,  and  was  ordered  quinine 
and  arsenic  in  large  doses.  In  September,  1880,  after  a 
hard  day's  work,  he  returned  home  at  10  p.m.,  and  had  a 
great  deal  of  gastric  trouble,  and  before  he  went  to  bed 
regurgitated  his  food  and,  mixed  with  it,  some  black  mate- 
rial. He  slept  well  that  night,  and  in  the  morning  had  a 
large  bloody  stool.  That  day  he  vomited  a  large  quantity 
of  blood  and  became  very  exsanguine.  After  this  time 
the  pain  increased  very  much,  but  it  was  always  relieved 
by  a  hearty  meal. 

In  November  and  December  he  was  in  the  hospital  on 
the  strictest  diet,  and  lost  in  this  time  about  forty  pounds 
in  weight.  He  improved  after  this,  and  in  July,  1881,  went 
abroad  and  was  away  for  two  years,  during  which  time  he 
had  much  discomfort  but  no  very  severe  attacks  of  pain. 

He  consulted  many  of  the  leading  physicians  of  Europe, 
and  the  diagnosis  was  uniformly  gastric  ulcer.  \Vhile  in 
Paris  he  had  slight  hemorrhage  from  the  bowels  without 
vomiting  blood.  He  returned  to  this  country  in  Decem- 
ber, 1882,  and  has  been  working  off  and  on  ever  since,  but 
never  entirely  free  from  gastric  distress,  occasionally  hav- 
ing severe  attacks  of  pain. 

In  January,  1887,  he  had  such  an  attack  which  lasted 
fourteen  days,  and  lost  twenty-eight  pounds  in  weight. 
He  has  repeatedly  had  to  take  morphia  in  large  doses  to 
relieve  the  pain.  The  patient  looks  well ;  weighs  one 
hundred  and  sixty-five  pounds  ;  tongue  clean ;  good  ap- 
petite ;  good  digestion.  Examination  of  the  abdomen, 
negative  ;  no  tenderness ;  no  tumor. 

Remarks. — These  two  cases  have  certain  points  in 
common.  In  the  first  place,  the  long  duration ;  the 
symptoms  in  one  instance  recurring  over  a  period  of 
eighteen  years ;  in  the  other  at  least  twelve  years.  The 
peptic  ulcer,  gastric  or  duodenal,  may  be  an  exceedingly 
chronic  malady,  lasting  ten,  fifteen,  twenty,  or,  according 
to  Brinton,  even  thirty,  years.     Anatomical  observations 


i.'U-,,. 


.J<-^ 


■.!  ■,        !■  : 


it. 

■   SP 


M 


i  ^  im^ 


show  that  a  large  proportion  of  these  ulcers  heal,  yet 
there  are  others  which,  from  their  general  condition,  can 
scarcely  be  repaired.  The  deep  excavation,  the  size  of  a 
dollar-piece,  with  hard  fibrous  base^  thickened  peritoneal 
coating,  and  indurated  edges,  which  we  find  so  often  in 
fatal  cases,  is  an  unlikely  ulcer  for  cicatrization.  The  time 
element  in  these  two  instances  gives  no  clue  whatever  to 
the  situation  of  the  ulcer. 

The  pain  in  gastric  and  in  duodenal  ulcers  is  very 
similar,  with  the  exception  of  the  time  of  onset,  which,  as 
a  rule,  in  gastric  ulcer  more  closely  follows  ingestion  of 
food,  while  in  the  duodenal  it  is  deferred  two  or  three, 
or  even  four,  hours.  This  is,  however,  an  uncertain 
symptom. 

In  Case  IX.  of  my  series,  close  questioning  elicited  the 
most  positive  statement  that  food  had  no  special  influ- 
ence, one  way  or  the  other,  in  inducing  or  in  aggravating 
the  pain,  which  was  more  likely  to  come  on  while  the 
stomach  was  empty  than  subsequent  to  a  meal. 

The  late  onset  of  pain  in  duodenal  ulcers  has  usually 
been  attributed  to  the  action  of  acid  chyme  passing  out 
of  the  pylorus  toward  the  close  of  gastric  digestion.  It 
is  to  be  remembered,  however,  that  the  chyme  passes 
continuously  from  the  stomach,  commencing,  probably, 
within  a  half-hour  after  taking  food.  The  increased 
acidity  of  the  gastric  contents  toward  the  close  of  di- 
gestion may  have  something  to  do  with  it. 

While  perhaps  too  much  stress  has  been  laid  upon  this 
point  in  the  differential  diagnosis  between  gastric  and 
duodenal  ulcers,  it  does  hold  good  in  certain  instances. 
A  more  important  criterion,  I  think,  is  in  the  occurrence 
of  gastric  crises,  agonizing  attacks  of  colic,  which  seem 
to  be  more  severe  in  the  duodenal  disease.  A  feature 
worthy  of  notice  is  the  occurrence  of  severe  gastralgic 
attacks  at  night. 

Absolute  immunity  from  all  gastric  distress  in  the  in- 
tervals between  taking  food  is  more  common  in  duodenal 
than  in  gastric  ulcer.  It  is  to  be  noted,  in  the  cases  here 
reported,  that  gastric  distress  has  been  more  or  less  con- 
stant. A  feature  common  to  both  ulcers  is  the  prolonged 
interval  ot  freedom.  In  Case  VIII.  of  my  series,  a  di- 
agnosis of  malarial  ga'-tralgia  was  made  by  an  eminent 
cUnician,  based  lar-cly  upon  the  fact  that  the  patient  had 
repeated  periods  of  complete  immunity  from  all  symp- 


heal,  yet 
ition,  can 
;  size  of  a 
peritoneal 
3  often  in 

The  time 
hatever  to 

rs  is  very 
,  which,  as 
gestion  of 
)  or  three, 
uncertain 

licited  the 

;cial  influ- 

ggravating 

while  the 

las  usually 
)assing  out 
;stion.  It 
me  passes 
probably, 
increased 
lose  of  di- 

1  upon  this 
;astric   and 

instances, 
occurrence 
vhich  seem 

A  feature 
:  gastralgic 

;s  in  the  in- 
n  duodenal 
cases  here 
)r  less  con- 
;  prolonged 
series,  a  di- 
an  eminent 
patient  had 
1  all  symp- 


character  ^""^"^^"^  ^^  ''"^'^''^  °^  ^^^  ^°^^  aggravating 
'rhe  point  upon  which  the  greatest  stress  has  been  laid 
in  the  diagnosis  of  duodenal  ulcers  is  the  occurrence  of 
melcena  without  haematemesis.     Bucquoy  and  Johnston 
Doth  hold  that  it  can  be  recognized  by  this  symptom 
alone.     If  so,  the  diagnosis  in  the  patients  whose  history 
IS  given  above  is  plain.     The  first  case  had  repeatedly 
passed  blood  from  the  bowels  without  hemorrhage  from 
the  stomach,  and  the  second  on,  at  least,  one  occasion 
As  already  stated,  it  was  this  symptom  which,  in  Case 
vni.  of  the   series  I   have   reported,  led    Dr.    Palmer 
Howard  to  suggest  the  existence  of  duodenal   ulcer      In 
the  above-reported  cases  I  should  hesitate  to  give  a  posi 
ti  ve  diagnosis  on  this  symptom  alone,  with  the  co-existence 
of  such  marked  gastric  disorder.     In  Johnston's  case  and 
in  several  of  Bucquoy's  patients,  I  grant  that  the  condi- 
tions for  a  correct  diagnosis  were  fulfilled,  and  I  accept 
the  importance  of  melaena  alone  as  a  valuable  localizing 
index ;  but  I  submit  that  instances  such  as  I  have  given 
illustrate  the  uncertainty,  rather  than  the  certainty,  which 
still  pertains  to  the  diagnosis  of  duodenal  ulcer 


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[Reprinted  from  The  Medical  News,  December  15,  1888.] 


OH  LESIONS   OF   THE   CONUS  MEDULLARIS  AND 
CAUDA  EQUINA.  AND  ON  THE  SITUATION  OF 
THE  ANO-  VESICAL  CENTRE  IN  MAN} 


By  WILLIAM  OSLER,  M.D., 

PROFESSOR   OF   CLINICAL   MEDICINK   IN  THE   UNIVERSITY  OP 
PENNSYLVANIA. 


There  have  been  published  recently  several  ob- 
^ervations  which  add  materially  to  our  knowledge  of 
injuries  and  lesions  of  the  terminal  section  of  the 
spinal  cord  and  of  its  nerve  roots,  and  which  also 
tlirow  considerable  light  on  the  exact  situation  of 
the  ano-vesical  centre. 

In  a  suggestive  and  valuable  communication 
•On  the  Segmental  Distribution  of  Sensory  Dis- 
orders," Ross' analyzes  the  distribution  of  the  sen- 
sory branches  of  the  lumbo-sacral  plexus,  and  calls 
attention  to  the  arrangement  of  the  lower  sacral  and 
foccygcal  nerves,  which  supply  by  the  small  sciatic, 
derived  from  the  third  and  fourth  sacral  roots,  the 
external  aspect  of  the  skin  on  the  back  of  the 
iliigh,  and  from  these  same  roots,  through  the  in- 

'  Read  before  the  Philadelphia  Neurological  Society.  October 

22,  i883.  ' 

''  Brain,  January,  i888. 


xcii 


XCI 


f 


r 


.9 


e 
e 

.'9 


If 

i 


9 


materially  enlarged  during  the  pa.st  twenty  vears,  has  increased 
with  each  decade  ;  in  1873-83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  .statistics  of  four  periods  we 
h^vejn^r853,  ^54,  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Read  by  ti(!e  before  the  Canada  Medical  Association,  Septemli^rim 


"rv 


3  OSLER, 

ferior  hemorrhoidal,  pudendal,  and  piidic  ni'ivc^, 
the  anus,  perineum,  scrotum,  and  penis. 

Cases  of  injury  have  been  reported  in  wliii  Ii  a 
sensory  paralysis  of  this  distribution  has  been  asMi- 
cialed  witli  paralysis  of  t]ie  rectum  and  bladder,  ai;,! 
with  little  or  no  involv  'ment  of  the  parts  sujiplioi 
by  tlie  first  and  second  sacral  and  the  lumbar  nvr\\\ 
Such  instances  are,  in  i'act,  important  and  valuaMr 
experiments  from  the  study  of  which  much  may  In 
gathered.  Thorburn'  reports  four  cases  of  injury  '  i 
the  Cauda  equina  in  which,  with  paralytic  symptoi„s 
of  variable  extent,  there  were  incontinence  of  uiin 
and  of  feces,  and  anaesthesia  in  the  distribution  .:' 
the  branches  of  the  lower  sacral  nerves.  He  (luoks 
also  a  r  ce  of  Olivier's  of  gunshot  wound  in  the 
lumbar  region,  which  nine  years  after  the  accident 
presented  complete  anaesthesia  of  the  postero-intenial 
and  anterior  parts  of  the  thighs  and  of  the  penis  ard 
scrotum. 

Bernhardt'  records  a  case  of  injury,  the  result  ofa 
fall  on  the  buttocks  from  a  height,  whicii  was  fol- 
lowed by  retention  of  urine  and  incontinence  of  feces. 
There  was  no  paralysis  of  the  legs,  but  there  was  ab- 
solute antesthesia  of  the  anus,  perineum,  scrotum, 
penis,  and  the  skin  of  the  upper  two-thirds  of  the 
thighs.  There  were  erections  and  within  a  few  weeks 
aftei  he  injury  coitus  was  possible,  but  ejaculation 
was  defective  and  the  semen  flowed  slowly  post 
cohabitationem.      Although  the  scrotum  was  anss- 


1  Brain,  January,  1888. 

2  Bernhardt :   Berliner  klin.  Wochenschrift,  No.  32,  18 


xcn 


Hsnviuletl    f 


il,  and  pudic  nerve., 
and  penis. 

reported  in  wliii  h  a 
ibiition  has  been  a^>n. 
"turn  and  bladder,  a\\\ 
:  of  the  parts  supiilin: 
and  the  hmibar  nervi  - 
nijortant  and  vahialik- 
f  wliich  nnich  may  lit 
J  four  cases  of  injury  fi 
ith  paralytic  synipton-.s 
i  incontinence  of  iiriiw 

in  the  distribnlion  ul 
;ral  nerves.  He  i|uoti> 
gunshot  wound  in  tl:.- 
ears  after  the  accidnit 
a  of  the  postero-intornai 
lis  and  of  the  penis  ard 

Df  injury,  the  result  of 
height,  whicii  was  lol- 
id  incontinence  of  feces. 
;  legs,  but  there  was  ali- 
us, perineum,  s(  rotiini, 
ipper  tsvo-thirds  of  the 
sand  within  a  il'w  weeks 
)Ossible,  but  ejaculation 
len  flowed  slowly  post 
the  scrotum  was  anss- 


chenschrift.  No.  32,  18 


V#»»»i    fha    Vi 


•  <•    U.M 


./  u... 


LESIONS    OF    THE    CONUS    MEDULLARIS.       3 

thetir.  the  testes  were  sensitive  to  pressure,  and  the 
.  reuKLstenc  reflex  was  present.  These  parts  are  sup- 
pl.ed  froin  the  genito-crural  nerve,  a  branch  of  the 
lun. Nar  plexus,  which  is,  as  Thorburn  points  out, 
usually  unaflected  in  these  cases. 

A  still  more  instructiveca.se  is  reported  by  Oppen- 
heun  ,n  the  last  n.imber  of  the  y/,r/./,./  Psvc/ua/ne, 
lid.  XX.  Heft  I.     A  workman  fell  from  a  height  of 
nuieteen  feet  upon  his  sacrum.     There  were  numb 
feelings  in  the  legs,  paralysis  of  the  bladder  and 
re.tuni,and  complete  anaesthesia  of  anus,  perineum 
scrotiun,    penis,    and   of  the  skin  on   the  postero- 
internal a.spects  of  the  thighs.     No  erections.     The 
reflexes  were  retained.     The  movements  of  the  legs 
r.re  perfect  and  the  numb   feelings   disappeared, 
llie  other  symptoms  persisted  and  death  took  place 
about  three  and  a  half  months  after  the  injury     The 
autopsy  showed  a  fracture  of  the  first  lumbar  verte- 
bra, and  a  traumatic  myelitis  and  haematomyelitis  of 
the  conus  medullaris,  and  a  degeneration  of   the 
posterior  roots  of  the  third  and  fourth  sacral  nerves 
roming  from  the  conus  at  the  .seat  of  injury      We 
liave  here  the  very  anatomical  facts  needed  to  com- 
plete the  picture,  and  they  moreover  render  it  very 
probable  that  in  these  cases  the  terminal  portion  of 
t  c  cord-the  conus-is  itself  the  seat  of  the  lesion, 
although  It  IS  possible  that  involvement  of  the  nerves 
alone  would  produce  the  symptoms. 

By  no  means  the  least  interesting  aspect  of  these 
cm  IS  the  light  they  throw  on  the  situation  of  the 
i;n.ves>cal  centre  in  man.     Kirchofl"'  had  already 


•  Archiv  f.  Psychiatric,  Bd.  xv. 


e 
s 

e 
e 

8 

1 

a 


4'i 


1 1 


■M 


!■ 


ill 


ill 


matenally  enlarged  during  the  pa.st  twenty  years,  ha.s  increased 
with  each  decade  ;  in  1873—83  a.s  maiij'  were  admitted  a.s  in  the 
previous  twenty  yeans.  Taking  the  .stati.stics  of  four  period.s  we 
^-^^i"i^^53.  '54.  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Read  l.y  title  l.cforc  the  Cnnada  Medical  Association,  Septcinher,  18SS. 


f !: 


v-m 


^  OSLER, 

concluded  that  it  wos  situated  in  the  conus  mcdiil. 
laris  in  the  region  of  exit  of  the  third  and  fnnrtl 
sacral  nerves.  In  the  case  of  a  man  who  had  lallm 
on  the  nates,  and  whose  important  symptom  was 
l)aralysis  of  the  bladder  and  rectum,  the  lesion  wa, 
found  in  the  conus  three  centimetres  above  \h 
filum  tcrminale.  Oppenheim's  case  is  a  still  nmk 
accurate  demonstration. 

The  following  case  can  be  understood  with  tli: 
aid  of  the  preceding  remarks  : 

Joe.   C.   H.,   ait.  sixty-three,  applied  at  tlie  In- 

firmary  for  Nervous  Diseases  Mart  h  7,  1888.    I'amilv 

history  good.     Has  always  been  healthy  and  wdl, 

though  as  a  young  man  he  had  syphilis.     Served  in 

the  army  and  on  June  8,  1862,  sustained  a  Iractiire 

of  the  spine.     In  the  battle  of  Cross  Keys,  as  he  was 

crossing  a  bridge,  a  bullet  struck  him  on  the  cartruli;e- 

belt,  and  the  shock  knocked  him  off  the  bridge,  and 

he  fell  on   the  rocks  in  a  sitting  posture.     He  was 

senseless,  and  on  coming  to  found  himsell  m  tk 

ambulance  wagon.     Was  in  the  military  hospitals 

three   and   a  half  years  at   Winchester  and  Fort 

McHenry,  for  three  years  of  which  time  he  was  on 

a  water-bed.     The  skin  of  the  back  was  not  broken 

bv  the  fall.     He  was  paralyzed  in  the  legs  and  lost 

control  of  the  bladder  and  rectum.      After  a  time  I 

he  coidd  move  the  legs,  but  he  did  not  walk  until 

December,  1865.     Since  that  time  he  has  been  able 

to  be  about,  but  he  has  never  regained  control  over 

the  bladder  and  rectimi.     Uses  a  catheter  three  or  | 

four  times  a  day.     Never  knows  when  he  is  going  to 

have  a  stool.  , 

Ffgsenf  Cofufi/ion.—WeW-buWt,  vigorous-lookin? 
man  for  his  age;  walks  well,  but  favors  the  leftside 


A'*t... ,'../*,/    frmu  //,<.    \\,„    V^^u   TU..U.„I    T^,., 


PiOll 


I  in  the  conus  metliil. 
f  the  third  and  fourth 

a  man  who  had  fallen 
iportant  symptom  wis 

rectum,  the  lesion  was 
centimetres  above  the 
ii's  case  is  a  still  more 

)e  understood  witli  th: 


ree,  applied  at  the  in- 
March  7,  1888.  Familv 
been  healthy  and  ucii, 
ad  syphilis.  Servid  in 
562,  sustained  a  fracture 
i{  Cross  Keys,  as  ho  wis 
ick  him  on  the  cartridge- 

him  off  the  bridge,  and 
itting  posture.  He  was 
to  found  himself  in  the 
1  the  military  hdspitaii 
:  Winchester  and  Fori 
f  which  time  he  was  on 
;he  back  was  not  broker, 
zed  in  the  legs  and  lost 
I  rectum.  After  a  time 
it  he  did  not  walk  until 
at  time  he  has  Ijeeii  able 
er  regained  control  over 

Uses  a  catheter  three  0; 
lows  when  he  is  going  to 

1-built,  vigorous-lookins 
1,  but  favors  the  left  side  | 


LESIONS    OF    THE    CONUS    MEDULLARIS.      5 


Distrilmtion  of  the  ancxstliesia. 
Front  view.  Hear  view. 

a  little.  When  stripped,  it  is  seen  that  the  left  leg  is 
slightly  smaller  than  the  right.  Measurements  gave 
right  calf  fifteen  inches,  left  thirteen  and  a  quarter 
inches;  left  thigh  also  somewhat  smaller.  He  says 
the  leg  has  been  thin  ever  since  the  accident,  but  he 
IS  always  able  to  get  about  quite  well.  The  spine 
IS  straight,  the  lower  dorsal  vertebrce  a  little  promi- 
nent, lumbar  normal ;  no  signs  of  abrasion  or  of  any 
scars;  no  pain  on  pressure. 
There  is  complete  anesthesia  of  the  lower  gluteal 


> 

e 
s 

'» 
e 
e 
i 

I 

i 


matenally  enlarged  dtiring  the  pa.st  twenty  years,  has  increased 
with  each  decade  ;  in  1873—83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  .statistics  of  four  periods  we 
hav^m_i853^'54^'55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Read  by  tiUe  before  the  Caiindn  Medical  Associntion,  September,  1888. 


6  OSLER, 

regions,  posterior  aspects  of  the  thighs,  perineum, 
scrotum,  and  penis  as  far  as  its  root.  In  all  other  re- 
gions sensation  is  perfect.  He  does  not  feel  the  luis- 
sage  of  a  catheter.  He  is  impotent.  No  informa- 
tion asked  about  seminal  emissions. 

Gluteal  reflex  well  marked. 

Cremasteric  reflex  present. 

K.-J.  +  +.     No  ankle  clonus. 

■  We  have  to  deal  here  with  a  residual  paralysis  of  the 
bladder  and  rectum  and  of  the  skin  supplied  by  the 
small  sciatic,  inferior  hemorrhoidal,  pudendal  nerws 
arising  from  the  third  and  fourth  sacral  roots. 
Whether  the  injury  involved  originally  the  cord  or 
only  the  branches  of  the  cauda  equina  does  not  seem 
possible  to  determine.  The  fact  that  slight  wasting 
of  one  leg  remains  would  indicate  a  neural  rather 
than  a  central  lesion. 

These  cases  do  not  all  result  from  injury.  Rosen- 
thal '  reports  the  case  of  a  woman,  aged  thirty,  who, 
as  the  result  of  exposure  to  cold,  had  incontinence  of 
urine  and  feces,  associated  with  anaesthesia  of  aims. 
perineum,  vulva,  vagina,  and  lower  gluteal  regions. 
The  legs  were  in  all  relations  normal.  From  a  con- 
sideration of  these  cases  we  may  conclude  : 

1.  That  the  ano-vesical  centre  in  man  is  situated 
in  the  lowest  segment  of  the  spinal  cord-— the  coiii;s 
meduUaris— at  the  region  of  exit  of  the  third  and 
fourth  sacral  nerves. 

2.  The  association  of  paralysis  of  the  rectum  and 


I  U.  jc     Jkis    centrum    Ano-vesicale,    Wiener    med. 
Nos.    J,  .' ,  and  20, 1888. 


Pres>e, 


x<zn 


P^m-!nf,d    frn,n  th».   AV,/,   Yn,-h  \Mi^alJnu,>^„l 


f  the  thighs,  perineum, 
ts  root.  In  all  other  ru- 
le does  not  feel  the  ])a.s- 
mpotent.  No  informa- 
issions. 


LESIONS    OF    THE    CONUS    MEDULLARIS.       J 

bladder  with  anaesthesia  in  the  distribution  of  the 
inferior  hemorrhoidal  and  pudendal  nerves  points  to 
a  les.on  of  the  lower  sacral  nerves  or  of  the  conus 
medullans^  It  is  not  always  possible  to  determine 
uhich  IS  affected. 


a  residual  paralysis  of  the 
the  skin  supplied  by  the 
rhoidal,  pudendal  nerves 
nd  fourth  sacral  roots. 
i  originally  the  cord  or 
ida  equina  does  not  seem 
t  fact  that  slight  wasting 
indicate  a  neural  rathur 

;ult  from  injury.  Rosen- 
^oman,  aged  thirty,  who, 
;old,  had  incontinence  of 
with  anaesthesia  of  anus. 
id  lower  gluteal  regions 
IS  normal.  From  a  con- 
may  conclude : 
;entre  in  man  is  situated 
le  spinal  cord — the  conns 
of  exit  of  the  third  and 


e 

s 

>> 
e 

e 
s 


iralysis  of  the  rectum  and 

jsicale,    Wiener    med.    Prese 


matenally  enlarged  citinng  tne  past  twenty  years,  has  increased 
with  each  decade  ;  in  1873-83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
hav^m^f853,  '54,  '55  a  death  rate  of  24.3  percent.;  18^.3,  '64,  '65, 

I  Read  hy  tiOe  before  the  CanadnMcdicRl  Associntion,  Septemlier,  i88,S. 


1 

i 

i  1 

;   r 

i.^  .iiiiW 


iiii 


u 


la 


11 


filfeS 


Reprinted  from  the  New  York  Medical  Journal 
for  Decemher  22,  1888. 


xaii 


d.-    /'^ 


v^^ 


.M 


^h ' 


K^  ■  1 


ON  A  FORM  OF  PURPURA 

ASSOCIATED  WITH  ARTICULAR,  GASTRO-INTESTINAL,  AND 

RENAL  SYMPTOMS. 

By  WILLIAM  OSLER,   M  D 

PROKKSSOB  OP  CUBICAL  MKmczNB  IN  THE  UNIVBR8ITT  O.  PENK8TLVANU, 

The  combination  of  purpnra  rhcnmatica  with  diarrhoea 
IS  frequently  referred  to  by  the  older  writer. 

The  cases  which  I  here  report  have  additional  features 
and,  With  others  to  be  found  in  tlie  literature,  belong  to  a 
very  remarkable  group  worthy  of  more  careful  study.  The 
clKiractcrs  are : 

T.  Recurring  outbreaks  of  purpura  often  associated  with 
urticaria  or  local  oedema. 

ir.  Articular  pain,  sometimes  with  swelling 

III.  Gastro-intestinal  disturbance-colic,  vomiting,  diar- 
rlid'a,  and  occasionally  hiPinorrhage. 

IV.  HaMnaturia,  albuminuria,  and  sometimes  a  fatal 
nephritis. 

Case  L-A  B.,  boy,  aged  six,  seen  January  23,  1888  with 

Dr  lun.         Norhe„,natie  liistor,  in  family  fso.Le  memb^ 

g    tj.    An  aunt's  clakl  on  father's  side,  aged  three  weeks 

'-1  of  purpura   ha-morrhagica.     The  child  has  been  excep-' 

■onal,,  well  deve  oped  and  strong.    During  the  past  summer 

le  Im led   somewhat  in   health.     The  present  trouble  begm 

on    tour  weeks  ago  with  pain  about  the  ankle,  fo.loweX 

attach  of  colic,  with  diarrhoea,  and  a  skin  eruption,  urticaria' 


d 
t- 

le 
ts 

le 
:e 
.>s 

h 

A 
1- 
i- 
1. 
n 


! 


ill 


^i'- 


.6 
te 

materially  enlarged  during  the  past  twenty  years,  has  increased 
with  each  decade  ;  in  1873-8.3  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
-''il^^M-  ;54.  '55  a  deatlM-ate  of  24.3  percent.;  1863,  '64,  '65, 

I  Read  by  title  before  the  Cnnadn  MclicaiAssociation,  September,  188S. 


f:^ 


11 


i  i 


I'l 


A   FOUM   OF   PURPURA. 

like  in  cbaructor,  which  te.ulo.l  to  beco.uc  purpuric.     Large 
are-is  were  blaclv  and  hUio,  jii>t  like  a  bruise. 

About  ten  clay,  after  the  beginning  of  the  Ulnes.  there  w. 
bleedir  from  the  bowels,  but  uut  in  large  au,ount.  Ihcr. 
:;::J:^tinall.orethanei..o.^^..st.s  — 

:;::;:r';:::^:::u"  :""e::ic^  .or  ti:;  pa. ... 
„J:'::.u.^,  «,o,.-i, ......  '■-";■■»;■;■.'.  2:^,0  ■; 

fnr.ner  i)luiup  condition.  Terai-crature,  98  ,  pulse  ao  tongue 
L  tl^^n-od;  abdon.en  slightly  protuberant  uot  pa.ntul  on 
Z^.  When  asked  where  the  pain  is,  he  always  place.  > 
'       ;  enlar.'ement  of  the  spleen  or  ot  tho 

!;::."|r.r^;^ro:';he  skin  over  the  elbows  there  is 

frVsl  roi.  of  eddish-brown  urticaria  wheals  rather  nu,,. 
Lm  a  d^ss  cden^atous-looldng  than  onlinary  h.ves;  there  ,b 
a  ntcl.  also  on  the  Hexor  surface  of  the  r>ght  ar>u.  Tho. 
loi  a  re  all  lu.nu.rrha,ic,  and  about  the  raised  ones  are  nunu.,- 
ousnudl  extravasations.  There  is  no  swelling  of  the  elbows. 
Tbout  the  buttocks  and  .highs  there  are  very  n.any  purpu,.. 
snots      No  swelling  of  tlie  ankles.  ...,.,     i  ,i 

'  An  attack  of  pain  can.e  on  during  the  v.s.t.  I  ad  . 
chani  t^r  of  o-di..ary  colic.  The  stools  were  brown,sh-bhuk  n 
c  but  contained  no  blood.     The  urine  was  clear;  s,k.  . 

!ravy  1-018,  containing  distinct  traces  ot  a  bunun.      Mun 
SopS  exanlination  showed  a  fe.v  red  blood-corpuscles  .ukI 

'^7ZX  ;::!r:;:tr  other  occasions  between  -lanuary  ... 

nd  February  7t'h.     About  the  25th  of  January  oedema  ot  tlie 

:ir  noticd.      This    increased,   the  scrotunj      cc.,,e 

swol  en,  and  within  ten  days  there  was  general  anasarca,     lb 

u^^ewas  highly  alhun.inous,  and  contained  tube-casts  and  „ 

^7d^3-n,elH.y  again,  ln.t  learned  froni  in.  ..nt. 
that  the   renal   symptoms   persisted,  and   these   assumed  ti,c 


A   FORM    OF   riTKPUR.A. 


lie  purpuric.     I-argo 


d.araotor  of  Bright's  disonso,  of  which  ulti.natelv  he  died  in 
iibout  six  wecl<s.  No  further  nrtioMlar  or  purpuric  symptoms 
(levelopeil 

(!,vsE  IF.— i:,irtlio]oiiiew  II..  a-od  forty-six,  machinist,  au- 

mitted  to  the  Philadelpiiia  Hospital.  Octoher  2Sth.  with  diarHuva 
an  extensive  purpuric  rash,  and  jxiiyarthritis.  Tlie  patient  has 
hoena  tolerably  iieaithy  man  ;  has  used  spirits  moderately  ;  no 
history  of  specific  disease;  lie  knows  of  no  similar  atfection  in 
Ills  family.  In  April,  1887,  he  had  a  severe  attack  of  gastro- 
intestinal disorder,  accompanied  with  -black  eruption,"  as  he 
describes  it,  on  his  legs,  similar  to  that  from  whicii  lie  now 
suffers.  There  were  no  spots  on  the  arms.  He  was  ill  at  this 
time  about  two  or  tliree  weeks.  Since  April  of  last  year  he  has 
been  failing  in  health,  and  has  had  several  sharp  attacks  of 
.linrrha>n.  The  present  attack  began  on  Saturday,  October 
20th,  with  pain  in  the  arms  and  knees,  and  a  rash  came  out  on 
the  elbows  and  legs.  Throughout  the  week  he  had  great  pain 
in  the  .joints,  and  the  knee-,  ankles,  and  right  elbow  became 
swollen. 

On  the  29th,  the  day  after  his  admission,  the  following  note 
was  made:  The  patient  is  a  moderately  well-nourished  man  • 
looks  pale ;  the  tongue  is  furred,  swollen,  and  indented.  Hotli 
dhows  tender,  not  swcdlen ;  complains  of  pain  on  flexing  the 
rijrht  arm.  On  both  arms  there  are  numerous  purpuric  spots 
from  1  to  3  mm.  in  diameter,  most  abundant  on  the  tlexor  sur- 
faces. Just  below  the  bend  of  the  right  elbow  there  is  a  large 
extravasation  the  size  of  a  quarter-dollar  piece,  which  is  a  little 
raised  at  tlie  center.  There  are  eighteen  or  twenty  spots  on  the 
extensor  surfaces  of  the  elbows;  no  extravasations  on  the  skin 
of  thorax  or  of  abdomen.  Ilij)  joint  not  painful  to  touch  or  to 
niovement ;  the  right  knee  is  a  little  swollen,  and  can  not  be 
tiexed;  the  right  ankle  is  not  swollen,  but  is  tender.  There 
are  numerous  fading  ecchymoses  on  the  extensor  surfaces  of  the 
thighs  and  many  on  the  skin  of  the  popliteal  spaces;  there  are 
none  on  the  legs.  During  the  examination  he  had  several  at- 
tacks of  colic.  The  urine  was  turbid  and  deposited  a  floeculent 
sediment  of  mucus.  On  boiling,  it  cleared  slightlv.  On  the 
addition  of  acid  there  was  a  distinct  deposit.     Microscopically 


\f- 


le 

IS 

h 
If- 


d 
I' 
i- 
i. 

Q 


!  f 


s\ 


1 1 J 


ma  enally  enlarged  during  the  pa.st  twenty  years,  ha.s  increased 
with  each  decade  ;  in  1873—83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
havc^m_i853,  •54,  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Rend  by  title  before  the  Canada  Medical  Association,  September,  188S. 


:■■    I    i 


t 


ii  : 


■5:  t 


4  A  FORM   i)V  PURPURA. 

there  were  leucocytes,  isoluteil  red  l-leod  cori-uscles,  nnd  a  few 
blood-casts.     He  has  had  proli.so  diarrham,  but  no  blood  in  tla- 

stools.  ,  ,        ,    • 

Octoher  30th.— Mvina  not  materially  reduced  in  aniomit. 
Specific  jjravity  1-016.  Chemical  and  microscopical  character> 
as  before.     Has  had  persistent  vomiting  to-duy. 

NoremUr  ht.—V&^^^A  a  restless  night;  vomiting  has  been 
very  distressing;  complains  a  good  deal  of  joint  pain  ;  the  lobes 
of  the  ears  are  very  tender  to  the  toiicli,  congested  and  red;  no 
distinct  extravasation  ;  the  right  elbow  is  red  and  swollen;  la^t 
night  e  fresh  eruption  of  puri)uric  si-ots  appeared  on  the  exte- 
rior surfaces  of  both  elbows ;  the  spots  are  raised,  and  look  like 
tho«e  of  purpura  urticans.  There  are  also  two  spots  on  the 
metacarpal  joint  of  the  left  index  finger.  The  ecchymoses  on 
the  flexor  surfaces  of  arms  have  faded.  The  knees  and  ankU. 
are  not  swollen.  Temperature,  100°;  pulse,  88,  small.  Heart 
soun.lfi  normal.     Tongue  still  coated  ;  gums  not  spongy. 

jth  —For  tlie  past  three  days  the  albumin  in  the  urine  Ims 
been  much  more  distinct,  and  there  are  many  tube-casts. 
Uric  acid  deposits  if  the  urine  is  left  standing.  Tlie  genenil 
condition  has  much  improved  ;  the  diarrhoea  is  checked,  and  he 
no  lon„'er  complains  of  abdominal  pain  ;  vomiting  is  not  so  dis- 

trcssiniJ. 

.;;(/;. —Patient  much  better  to-day;  no  joint  pain;  the  ec- 
chymoses have  a'  .lOst  faded,  and  the  vomiting  is  checked. 

From  this  date  the  recovery  was  rapid,  and  at  present  (hito 
(November  30lh)  convalescence  is  established.  The  urine  is 
still  albumin.ms.  The  treatment  consisted  in  the  administra- 
tion of  naphthalin  with  Dover's  powder  for  the  diarrhani  and 
colic,  and  increasing  doses  of  Fowler's  solution. 

Remarks.-k\k\n^on,  in  Pepper's  "System,"  vol.  ii,  re- 
fers to  this  form  of  purpura  as  described  by  lleiiocli 
("Berliner  kliu.  Woclienschrift,"  1874),  and  by  Coiity 
"Gazette  hebd.inadaire,"  1876).  The  latter  author,  i.i 
an  exhaustive  article,  has  collected  a  large  number  ot  cases, 
and  describes  the  disease  as  "  «».e  espke  de  purpura 
dWigine    nerveuser      Wagner    (Archiv    dcr    lleilk.u.de. 


n'lmscles,  nnd  a  few 
but  no  blood  in  tin.- 

educed  in  nniouiit. 
oseopical  clmrneter> 
day. 

vomiting  bas  been 
oint  pain  ;  tiie  lol)e.~ 
ngested  and  red;  w 
ed  and  swollen;  la>t 
)peared  on  tlie  ext* - 
raised,  and  look  like 
io  two  spots  on  tlie 

The  eccbymoses  on 
he  knees  and  ankK  ^ 
se,  88,  small.  Heart 
IS  not  spongy, 
min  in  the  urine  bus 
iro  many  tube-casts, 
mding.  Tiie  geneiiil 
jeais  checked,  and  lie 
oniiting  is  not  so  dis- 

0  joint  pain  ;  the  ei - 
ling  is  checked. 
1,  and  at  present  duto 
lished.  The  urine  is 
ed  in  the  admiuisiiM- 
for  the  diarrh(jea  and 
lution. 

'  System,"  vol.  ii,  vc- 
•scrlbcd  by  Houocli 
!74),  and  by  Oouty 
'he  latter  author,  in 
irge  number  of  cases, 
(  espece  de  pit rp urn 
nv    der    Ileilkuiulo," 


A    FORM   OK   PCRPURA.  g 

U(l.  x)  and  Zimniennann  ("  Archiv  der  Ileilkunde,"  187o) 
liavo  also  reported  oases  idontical  with  those  above  des(Mil)ed 
With  the  exception  of  a  paper  by  15iiiot  on  "  Purpurd  hewor- 
rhar/lque  avec  oedemes  mohilea  et  crises  inh-sfimiks'^  ("  Revue 
iiuhI.  de  la  Suisse  Roin.,"  188(i)  I  Hnd  no  very  recent  ac- 
counts in  the  journals, 

I  think  these  jases  come  properly  under  the  designation 
imrpura  rheumatica,  of  which  they  constitute  the  most  an-- 
gravated  and  serious  form.  The  varieties  of  this  condition 
may  be  pjrouped  as  follows:  1.  Cases  in  which  the  purpura 
occurs  with  slight  articular  pain,  or  witii  diarrluea  alone,  or 
in  which  the  eruption  comes  without  these  symptoms  in 
children  who  have  had  rlieumatic  manifestations.  2.  Acute 
arthritis  involving  many  joints  and  associated  witli  exten- 
sive yj^^ry^wra  urticans — the  pe/iosis  rhemiutUca  of  Schonlein. 
;i.  The  variety  here  described  in  which,  with  articular  ati'ec- 
tion  and  purpura,  there  are  gastro-intestinal  crises,  luemor- 
rliages  from  certain  of  the  mucous  surfaces,  albuminuria, 
iind  in  some  cases  a  fatal  nephritis. 

Are  these  cases  truly  rheumatic,  or  is  not  the  articular 
atl'ection  upon  which  so  much  stress  is  laid  analogous  to 
tliat  which  we  see  in  luemophilia  and  scurvy  ]  It  is  diffi- 
cult to  escape  from  Mie  former  view  in  the  presence  of 
characteristic  cases  of  peliosis  rheumatica  with  endocarditis 
and  pericarditis;  and  yet  the  close  relationship  and  even 
iiitorchangeability  of  certain  of  these  cases  of  purpura  with 
urticaria,  with  erythema  nodosum,  and  with  the  angio-neu- 
rotic  oedema,  favor  the  suggestion  that  the  entire*  group 
may  depend  upon  some  poison — an  alkaloid,  possibly,  the 
result  of  faulty  chylopoietic  metabolism — which,  in  Vary- 
inn'  doses  in  ditiorent  constitutions,  excites  in  one  urticaria, 
in  a  second  poliosis  rheumatica,  and  in  the  third  a  fatal 
form  of  purpura. 


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materially  enlarged  during  the  past  twenty  years,  has  increased 
with  each  decade  ;  in  1873—83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
havem  i853,j54,  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Rea.l  by  title  before  the  Canada  MedicarAssocration,  September,  1888. 


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materially  enlarged  during  the  past  twenty  years,  has  increased 
with  each  decade  ;  in  1873—83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
-i^i"L^53'  '54,  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

I  Read  by  tille  before  the  Canada  Medical  Association,  September,  iSSS. 


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FROM   TllIC   rNIVKRSITV 

Mkdicai,  Maca/im;. 


THE  MORTALITY  OF  PNEUMONIA.' 

By  Wiluam  Osr.KK,  M.  D., 

Professor  of  Clhiical  Medicine,  University  of  Pcnusvlvania.-     Pl,y- 

siciati  to   tlie  University  and  Philadelpliia    Hospitals 

and  the  Infirmary  for  Nervous  Diseases. 

Whether  or  not  the  inortaUty  from  pneumonia  li-.s  increased 
of  late  years,  and,  if  so,  to  what  cause  or  causes  this  is  to  l)e  at- 
tributed aie  questions  of  the  utmost  practical  importance, 

What  are  the  facts  as  to  the  increase  in  mortality  ?  The 
last  United  States  Census  Report  gives  a  total  of  63,053  deaths 
from  this  disease  ;  8,330  in  each  100,000  deaths  from  all  causes 
against  8,128  in  1870  ;  6,874  i"  i860  and  3,755  in  1850,  with  the 
mean  age  of  death  at  32.  If  correct,  these  figures  would  indicate 
an  extraordinary'  increase  in  the  mortality,  but  Dr.  Billings  writes 
"  that  the  conclusion  cainiot  be  drawn  that  the  mortality  has  in- 
creased, because  in  preceeding  years  the  data  were  very  much 
more  imperfect  and  unreliable.  ' ' 

The  statistics  of  the  large  hospitals  do  not  show  any  decided 
increase.  I  have  taken  the  figures  of  three  representative  institu- 
tions ;  the  Montreal  General  Hospital,  in  the  North  ;  the  Penn- 
sylvania Hospital,  and  the  New  Orleans  Charite,  in'  the  South. 
At  Montreal  the  statistics  are  available  since  1853,  and  we  find  in 
the  decade  1853—63  a  mortality  of  16.2  per  cent.,-  decade  1863— 
73amortality  of  20.3  per  cent;  a  total  of  1012  ca.ses  with  206 
deaths  equal  to  20.4  per  cent.  It  is  interesting  to  note  that  the 
total  number  of  cases  admitted  to  this  hospital,  which  has  not  been 
materially  enlarged  during  the  past  twenty  years,  has  increased 
with  each  decade  ;  in  1873—83  as  many  were  admitted  as  in  the 
previous  twenty  years.  Taking  the  statistics  of  four  periods  we 
h^vein  1853,  '54,  '55  a  death  rate  of  24.3  percent.;  1863,  '64,  '65, 

1  Read  by  title  before  tlie  Canada  Medical  Association ,  September,  1888. 


!l 


; 


\  i 


,  iiassa.] 


, 2  per  cent.;  I S73.  '74.  '75.  29.1  F^r  cent.;    rSS^.   'S4,    '85,    16.1 
percent.;  figures  wliich.l..  not  indicate   a    regularly    progressive 

increase  in  the  mortality. 

Hy  the  kindness  of  Dr.  Matas  I  have  heen  enabled  to  get  the 
statistics  of  the  Charite  Hospital  of  New  ( )rleans  since  i  S.v ..  In 
decades  the  death  rate  has  been  as  ft)llo\vs 

1S30 — 39    -     2 9S  cases    -      died  133 

"   242 

-   "  37« 
"  429 


1 840 — 40 
1850—59 
1 860 — 69 
1870—79 


-  685 

-  1 172 

-  747 

-  K)f)7 


percentage  44. fi 

' '  ^2.2 

43-9 

"  40. 3 


Total.     -     -     -    3969  'S'^^  3«-"i 

Here  too  figures  do  not  indicate  that  there  has  been  a  very 
marked  increase.  There  was  a  slight  reduction  in  the  decades 
from  1840  to  i860,  bnt  the  ri.se  in  the  sncceeding  periods  never 
reached  the  maximum  attained  in  1S30  to  1839.  The  well  known 
great  fatality  of  pneumonia  in  the  South,  particularly  among  the 
negroes,  is  born  out  by  thes  statistics. 

At  the  Penn.syh mia  Hospital  the  following  are  the  returns 
which  were  kindly  furni.shed  me  by  Dr.  F.  Packard,  Resident 
Physician.  Dr.  Hartshorne,  in  his  paper  before  the  College  oi 
Physicians  of  Philad  Iphia,  quoted  the  mortality  in  three  years  of 
the  4th,  6th  and  8tli  decade.s  to  show  a  progressive  increa.se  in  the 
death  riiti-,  which  might  possil  ly  be  attributed  to  changes  in  the 
methods  of  treatment.  There  is  indeed  an  increase,  as  shown  in 
Table  I,  but  four  other  periods  of  three  years  in  successive  de- 
cades illustrate  the  beautiful  elasticity  of  figures  and  show  that 
the  mortality  has,  if  anything,  been  reduced. 
I. 


II. 


1845-46-47 

1855-56-57 
1865-66-67 

1875-76-77 
1885-86-87 


16  percent. 

25-4  "  " 

24.1  "  " 

.^9-2  "  " 
36.1 


1848-49-50 
1858-59-60 
1868-69-70 
1878-79-80 


37.9  per  cent. 
21.2  "     " 

22.8  "     " 

.^2.7 


In  a  total  of  704  cases  .since  1845  the  mortality  has  been  29.  i 

per  cent.  . 

In  the  Boston  City  Hospiial  the  death  rate  for  the  past   thir- 
teen years  has  been  29.1  per  cent.,  a  total  of  1443  cases  with   421 

deaths.  .    •        r  ., 

I  regret  that  I  have  not  been  able  to  get  the  .statistics  of  tlic 
Philadelphia  Hospital,  but  I  .shall  allude  in  a  few  moments  to  the 


.1 


has  been  29. 1 


very  lii^li  rale  ol' iiiorlalily  in  tlial  iiistitiitinii. 

It  is  very  generally  aekii.nvledKed  llial  the  death  rate  prior  to 
..S40.  in  the  days  of  active  aiitiphloKislie  measures,  was  very  iiiueh 
liiKljer  that!  under  the    rational    methods    since   eni])loyed.     Cer- 
tainly, the  figures  ([uot,,,!  l,y  Wilson  Im.x  in  Revnold's  System    of 
Medicine  support  this,  and  show  particularly    that    the    mortality 
was  greater  when  bleeding  was  employed.   Xot  to  enter  into  details 
which  are  .so  acce.ssil)le,  it  will  I.e  sunicient  to  recall  the  remarka- 
ble records  of  the  Ivdinburgh  Innrniary.      IJefore   1H4H    the   death 
rate  in  567  cases  was  ,V'..l  per  cent.;    from    i,S4,s    to   1X56   in  611 
cases,  2r.2  percent,;  and  from  1X56  in    54,s    ca.ses   the    mortality 
was  only  12.7  per  cent.      In    hicksoii's   able    K.s.say    on    Pneumo- 
nia' the  .statistics  of  So,  437  were  collected  with  a  nio'rtalitv  of  1^,915 
giving  the  proportion  of  deaths  I  in  4.,s.     This  writer   alludes    to 
the  remarkable  ecpiality  of  the  proijortional  mortality— •' in  p..ice 
and  ail  comfort,  in  hospitals  of  wealthy  conununities,  in  the    field 
of  destructive  war,  and  in  the  ho.spitals  and  barracks,  the  emphatic 
.seats  of  destitution    jirlvation,  exposure  and  neglect    ' 

The  retin  n  >f  the  Montreal  Ho.spital,  the  Pennsylvania  Hos- 
pital an  c  New  Orleans  Charite  certainly  do  not  bear  out  Dr. 
Hartshorn's  .strong  statement  that  the  "  mortality  of  pneumonia 
to-day  is  under  similar  circumstances,  more  than  twice  as  great  as 
it  was  forty  years  ago.^  The  truth  would  .seem  to  be  tliat  in  our 
large  city  ho.spitals  the  death  rate  in  pneumonia  always  has  been, 
and  is  likely  tocontiuue  tobe  very  high,  usually  over  25  per  cent', 
often  reaching  40  or  50  per  cent.  Tufortunately  it  is  upon  the 
statistics  of  these  institutions  that  we  depend  for  our  information 
and  we  have  not  similar  large  return^  in  private  practice  with 
which  to  compare  them.  The  Collective  Investigation  Committee 
of  the  JJriti.sh  A.ssociation  recently  jiublished  a  report  of  cases 
drawn  largch-  fn^n  i)rivate  pratlice,  with  a  mortality  of  18  per 
cent.,  a  ratio  considerably  lower  than  thuL  in  hospital  practice.  As 
illustrating  the  difference  between  private  and  hospital  practice  in 
llie  .same  city,  I  may  state  that  the  death  rate  among  170  cases 
treated  by  Dr.  Palmer  Howard  of  Montreal  in  twenty  years  was 
only  6  per  cent.,  a  striking  contrast  to  the  rate  of  mortnlity  at  the 
General  Ho.spital  during  the  same  period  We  nmst  remember 
thai  the  paup-r  population  in  the  large  cities  of  this  country  has 
developed  enormously  in  the  past  twenty  years,  causing  a  very 
great  relative  increa.se  in  the  number  of  individuals  who  live  under 

I  Stiuiics  in  I'atlioloxv  and  TherapcnUcs,  iSfi; 
sioianscffl/'lhlplll!;-.  ""••^^"'•'•"■^  1'  'I"'-  'listnl.nto.!  to  th.  .Vllowsoftlu.  CoHckc  ofrhy- 


11 


L 


I  ; 


■■'  f  '  '•it  u 


conditions  which  render  them  more  susceptible  to  and  less  able  to 
withstand  such  an  acute  affection  as  pneumonia.  To  this,  I  think, 
we  may  reasonably  attribute  an)-  slight  increase  in  the  death 
rate  which  may  have  occured  at  certain  hospitals. 

In  a  self-limited  fever  like  pneumonia  it  is  highly  improbable 
that  any  great  increase  in  the  death  rate  has  followed  a  change  in 
the  methods  of  treatment.  77/<'>r  /s  )io  acute  discciM'  7,  ■////  so  Jcu  • 
cases  in  7vhich  the  /ssne  of  life  and  death  lies  in  the  adntinistmtion 
of  druf^s.  \\\  young,  hcaltliy  aduits  ■A\i\x<g^\w^yox\\.y  of  the  cases 
do  well  without  any  medicine,  and  every  session  I  treat  in  this  way 
eight  or  ten  such  ca.ses  for  the  purpose  of  impressing  upon  stu- 
dents the  lesson,  .so  hard  to  learn,  .so  often  never  learnt,  that  dosing 
is  not  the  Alpha  and  Omega  of  practice.  Ikit  a  third  or  more  of 
the  cases  demand  imperatively  active  treatment  from  the  outset,  and 
and  yet  the  records  we  have  been  di.scussing  tell  how  unsatisfac- 
tory, how  futile  our  present  methods  in  dealing  with  the  .severer 
forms  of  the  di.sea.se.  Take  an  illustration  :  I  had  in  the  Phila- 
delphia Ho.spital,  eleven  cases  under  my  care  during  the  months 
of  December  and  January,  of  which  six  recovered  and  five  died. 
A  brief  account  of  the  latter  will  give  an  idea  of  the  nature  of  the 
cases  which  swell  the  mortality  bills  at  our  general  ho.spitals. 

James  D.,  cet.  22,  healthy  young  man,  worked  until  January  6th;  ad- 
mitted on  the  T3th  with  consolidation  of  lower  lobe  of  riji^ht  lunjr.  The  fever 
was  not  high,  he  was  conscious  and  for  two  days  did  well,  but  on  the  i6th 
there  was  evidence  of  involvement  of  the  lower  lobe  of  the  left  Unijj;.  He 
had  profuse  diarrhcea.  The  temperature  range  was  102°  to  103.°  On  the 
iSth  and  19th  the  pulse  became  more  rapid  and  the  respiration  rose  above 
55,  and  there  was  consolidation  of  the  entire  right  lung  and  all  of  the  lower 
lobe  of  the  left.  Death  took  place  on  the  20th,  The  autopsy  showed  uni- 
form hepatization  of  the  right  lung,  and  the  old  pleuritic  ailhesions,  (he  had 
lia<l  pneumonia  some  years  before).  Consolidation  of  the  left  lower  lobe 
and  of  an  inch  along  the  lower  margiii  of  the  upper  lobe.  There  was  a  large 
patch  of  fresh  myocarditis  in  the  septum  ventriculorum. 

In  this  case  the  death  was  due  to  direct  involvement  of  an 
unusually  large  extent  of  lung  substance.  The  usual  rotitine  stim- 
ulating and  supporting  measures  were  employed  in  this  case,  l)ut 
without  any  perceptible  benefit.  The  inhalations  of  compressed 
air  seemed  to  do  more  good  than  anythingel.se.  W'oidd  a  copious 
bleeding  on  admission,  the  6th  day  of  the  disease,  have  prevented 
the  extension  to  the  other  lobes  ? 

This  is,  however,  an  exceptional  ca,se  for  the  IMiiladelpliia 
Hospital.  Young  healthy  fellows  with  pneumonia  usually  do 
well.  Here  are  some  every-day  cases  when  the  disease  is  ]>reva- 
lent. 


Jeff.  K,  ict.  25,  bartender,  brought  by  police  patrol  on  the  21st     Ila.l  been 
.Irniking  heavily  lor  three  or  four  months.     Attacked  suddenlv  on  the  20th 
Violently  delirious  on  the  21st  anf  22<1 ;  had  to  be  constantU-  watched  an.l  re- 
strained.    Temperature  103-104^^;  signs  of  pneumonia  atri-ht  base.     On  the 
23d  profoundly  unconscious.     IX'ath  on  the  moniing  of  the  24th. 

I.  M.  I).,  at.  4",  painter.  Had  pneumonia  twenty  vears  ago  V  hird 
dnnker,  was  on  "spree-  and  sat  up  hi  a  bar-room  on  bVidav  night  tlie  2,vl 
Had  pains  m  cliest  and  cough  ne.xt  day.  On  the  26th  was  admitted  to  the 
venereal  ward  avd  there  had  a  chill.  When  transferred  H,  the  medii-al  ward 
the  emperatur,  as  .(,4^  pulse  120,  respiration,  40.  Signs  of  consolidation 
of  right  apex,  u  ch  had  rapidly  extended  and  by  the  ist  had  involved  the  * 
entire  lung.  The  tongue  was  dry  and  tremulous  and  iie  had  low  delirium. 
The  pulse  feeble,  120-130.  Resjiiration  not  very  rapid,  rarely  aI)ove  40  per 
niinute.  Death  on  the  morning  of  the  3d.  The  autopsy  showed  pneumonia 
of  right  lung  and  marked  interstitial  nephritis. 

William  N.,  tet.  25,  rag  picker,  very  hard  drinker.  On  Saturday  De- 
cember loth,  drank  very  heayily  ;  was  out  all  night  and  much  ex]K.se<lin  the 
cold,  On  Sunday  nth,  had  a  chill  with  pain  in  left  side.  On  i6th  w-is 
brought  by  ambulance  to  the  Hospital  and  a.lmitte.l  to  the  ward  for  drunk- 
ards. He  was  delirious,  with  a  dry  tongue  ;  pulse  135,  respiration  35.  at  left 
base.  During  the  first  week  the  temperature  ran^v  v.r>s  not  high,  100—102° 
pulse  17  2— 1 2,S  respiration  40  to  50,  and  the  delirium  was  the  m'o.st  serious 
spinptom.  From  the  24tli  to  the  27th  profuse  diarrhrea.  Gradual  failure  and 
death  on  the  3d. 

Thomas  L.,  :et.  30,  a  heavy  drinker,  l.ell  on  Saturday  7th  in  a  pit  and 
cut  his  head,  which  was  dressed  at  the  I'ennsvlvauia  Hospital.  Was  seen 
by  Dr.  Kdwards  on  Monday  9th,  at  10  A.  M.,  and  then  looked  like  a  man  in 
the  early  stage  of  delirium  tremens.  Was  sent  to  the  Hospital  and  admitted 
to  the  Avard  for  drunkards.  In  the  evening  was  conscious.  Temperature 
104 ><°,  pulse  120,  respiration  34.  Was  very  delirious  through  the  night,  and 
in  the  morning  there  were  signs  of  pneumonia  at  the  right  liase  and  he  was 
transferred  to  the  medical  ward.  At  .  1>.  M.,  he  wasactiyelv  delirious,  pulse 
120,  respiration  40  temperature  104.4-5°.  Much  tremor;  lips  a  little  cyan- 
otic. Soldification  of  right  lower  lobe.  He  gradually  became  (juieter.  Tem- 
perature rose  to  105.4  5°,  respiration  70,  pulse  120,  and  he  died  shortly  after 
mid-night,  al)out  thirty-two  hours  after  admission.  The  autopsy  showed 
red  hepatization  of  the  lower  and  middle  lobes  of  the  right  hnig.  '  Ki.lneys 

These  are  fair  ilht.statious  of  the  fatal  ca.se,s,  which  are  .so  com- 
mon at  the  Philadelphia  Hospital  and  similar  instittitions  which 
admit  the  pauper  .sick.  f)ccasi<)nallv  a  loiigh-fihred  drunkard 
will  survive,  hut  as  a  rule  tlie  disea.se  is  fatal  in  tho.se  who  are  at- 
tacked while  under  the  infltience  of  alcohol.  Often  the  patients 
are  admitted  moril>u;id  or  extremely  cyanosed.  Last  winter  I  had 
three  such  cases  bled  with  temporary  relief  to  the  engorged  ven- 
(nis,>^/stein,  but  without  retarding  the  downward  course  of  the 
diseasv  Could  we  exclude  from  our  tables  the  subjects  of  chronic 
a  choholism,  I  am  sure  lh:i.,  even  at  th  ■  Philadelphi:i  Hospital, 
llie  death  rate  from  pneumonia  would  not  be  more  tlian  S  or  10 
per  cent. 


II 


i  'i;r 


The  serious  complications  of  pericarditis,  myocarditis,  endo- 
carditis, meningitis  or  colitis  cause  death  in  many  healthy  persons 
attacked  with  the  disease,  but  a  careful  examination  of  post-mor- 
tem records  will  show  that  apart  from  these  complications  the  fa- 
tal cases  usually  show  signs  of  more  or  less  extensive  disease  ni 
other  organs,  interstitial  nephritis,  fatty  liver,  fatty  heart  or 
chronic  endarteritis.  I  was  nuich  impressed  with  this  m  review- 
ing the  records  of  loo  autopsies  in  this  disease  which  I  made  in 
.  Montreal.-  Kxcluding  the  cases  with  almost  necessarily  iatal 
complications,  and  those  with  serious  alterations  in  important 
viscera,  but  a  small  number  remained  in  which  a  simple  pneumo- 
nia however  extensive,  killed  a  healthy  man. 

'  A  good  many  complicated  factors  combine  in  an  individual 
to  cause  death,  but  studying  the  fatal  cases  of  pneumonia  as  so 
many  lessons  from  which  to  learn  wisdom  for  the  future,  we  may, 
I  think,  divide  them  into  three  groups,  ist.  Tho.se  in  which 
the  death  has  resulted  from  such  complications  as  gangrene,  men- 
ingitis ulcerative  endocarditis,  conditions  at  present  l)eyoiid  our 
art  to  remedy.  2d.  Cases  in  which  death  has  resulted  from  me- 
chanical causes,  over-disteiuion  and  paralysis  of  the  right  heart. 
3d  The  large  group  in  which  death  has  been  due  to  failure  of  the 
geiieral  powers  under  the  influence  of  the  high  fever,  or  of  the 
specific  poison,  or  of  both  combined. 

We  are  likely  to  be  deceived  in  our  therapeutical  conclusions 
unless  we  bear  in  mind  the  unquestionable  fact  that  a  very  large 
proportion  of  all  cases  of  simple  acute  pneumonia  in  healthy  ad- 
ults recover  without  the  u.se  of  drugs.     Careful  nursing,   feeding, 
local  applications,  keep  the  bowels  open  and  the  skin  active,  meet 
the  indications.     Kven  cases  of  great  severity  with  extensive  in- 
volvement of  the  lung  we  .see   the  crisis  occur  normally   under 
most  adver.se  circumstances.     Such  a  case  occurred  last  session  at 
the  Philadelphia  Fo.spital.     The  patient,  ijdmitted  on  the  seventh 
day  of  the  disease,  had  been   up  and  about  at  his  lodging  and 
drinking  heavily,  and  had  had  neither  medical  nor  domestic  care. 
Although  delirious  on  admission,  the  crisis  occurred  on  the  morn- 
ing of  the  eighth  day  and  he  entered  upon  a  convalescence  as  sat 
isfnotory  in  every  respect  as  if  he  had  had  the  most  approved  an- 
tiphlogistic treatment. 

I  have  often  puzzled  over  the  cadavers  of  persons  dead  ol 
pneumonia  and  asked  why  should  this  man  have  died?     Too 

~"i  Canada  Mc.lkal  and  SnrRical  Journal.  .SS5.    Trans,  of  Ha'   n,ila,l.l,.l.ia    I'allw.l  «i 
cal  Society,  vol.  xii. 


ti  itulividual 


often  the  answer  is  the  echo  of  the  question.  The  cause  is  evi- 
dent in  inan^-  cases  in  the  form  of  serious  complications,  such  as 
endocarditis  and  meningitis.  .Some  years  ago  I  was  struck  in  the 
post-mortem  room,  with  the  cases  of  young  vigorous  men,  who 
had  died  with  distended  right  hearts  and  systemic  veins  and  ex- 
tensive, though  in  some  instances  limited,  areas  of  consolidation. 
It  seemed  as  if  the  heart  had  failed  in  o\-er-distension — asystole — 
and  I  determined,  when  the  opportunity  arose,  not  to  let  such 
cases  die  without  a  copious  venesection.  Clinically,  I  think,  we 
see  this  condition  in  two  different  periods  of  the  affection.  There  is 
an  early  cardiac  embarrassment  during  the  first  few  days  of  the 
disease,  leading  to  .slight  cyanosis  ;  and  in  a  later  period,  at  the 
-th — loth  day,  we  .see  with  increasing  anxiety,  the  changing 
color,  a  dull  suflFu.sion,  a  deepening  hue,  then  the  marked  cyano.sis. 
Uleeding  may  be  indicated  at  both  these  periods.  In  hospital 
practice  we  more  commoidy  .see  the  patients  in  the  latter.  For 
ten  years  past  I  have  practiced  free  bleeding  to  the  amount  of  from 
20  to  25  ounces  in  adults,  and  yet  I  have  to  confess  to  disappoint- 
ment in  my  results  I  have  seen  but  one  case  recover  after  bleed- 
ing, out  of  twelve  or  fifteen.  The  ca.ses  of  bleeding  in  the  late 
stages  have  been  uniformally  fatal.  I  know  they  have  often  been 
performed  with  the  patient  in  cxireinis,  but  it  .seems  imperative  to 
attempt  to  relieve  an  over-distended  circulatory  system.  I  know 
it  does  relieve  in  the  cyanosis  of  cardiac  dilatation  from  other 
cau.ses,  but  in  pneumonia  there  are  doubtless  conditions  other  than 
mechanical.  In  these  cases  the  administration  of  oxygen  or  com- 
pressed air  is  often  most  .serviceable.  Complications  carry  off  many, 
and  direct  cardiac  failure  not  a  few,  but  both  together  do  not  num- 
l>er  the  ca.ses,  which  we  .see  gradually  fail  under  the  continued  in- 
fluence of  the  fever,  the  disturbed  cardiac-respiratory  mechani.sm 
and  the  poison.  Here  we  are  are  often  baffled,  btit  in  this  group 
we  .see  repeatedly  the  beneficial  effects  of  the  timely  use  of  cardiac 
and  respiratory  stimulants. 


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[ReprintiHl  from  Thk  MkdicaL  NliWs,  April  ij  ,111, 1 


389.J 


ON   PHAGOCYTES. 

An  Address 

before  the  Alumni  Association  of  Bellevue  Hospital,  New  York, 

delivered  April  j,  1S80. 

By  WILLIAM  OSLER,  M.D., 

PROFESSOR  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OP  FFNNSYLVANIA . 


^M^ 


There  are  in  the  body  groups  of  tissues  possessing 
cells,  v:>ich  either  normally  display  amoeboid  changes, 
or  are  capable,  under  certain  conditions,  of  assuming 
them.  By  amoeboid  properties  we  mean  not  only  the 
capability  of  free  movement,  but  the  possession  of  a 
power  which  enables  a  cell  to  take  foreign  particles  into 
its  interior.  Tissues  containing  such  cells  are  derived 
from  the  mesoderm,  the  type  of  which,  phylogenetically, 
is  a  free  wandering  cell.  (Minot.)  In  the  development 
of  this  layer  epithelial  and  non-epithelial  portions  may 
be  distinguished.  For  the  former  Minot  has  suggested 
the  term  mesothelium,  and  the  latter  His  catls  me- 
senchym.  The  distinction  between  the  two  is,  however, 
largely  artificial,  as  the  epithelium  maybe,  and  in  places 
is,  in  development  changed  into  connective  tissue.  And, 
thirdly,  there  are  in  the  mesoderm,  at  all  stages  of  its 
development,  certain  cells  which  are  free  and  inde- 
pendent—mesamoeboids  (Minot),  and  which  persist  sub- 
sequently as  leucocytes. 

These  mesodermic  tells  in  the  adult  body,  which  are 
capable  either  of  free  amoeboid  movements,  or  of  taking 
up  into  their  protoplasm  solid  particles  of  various  sorts, 
are  met  with  : 


\  :  i- 


!    i 


tenderness  on  palpation.  -  ■i,-,i,.irui.t!»,-r, ■.,»>-,, n-  i,,,,i'- 

I  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
his  distressed  appearance.  He  hiv  propped  up  in  bed,  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature   100^     He  complained  of 

'  Rood  by  title  at  tlie  meeting  uftlie  Aesocitttluu    f   .mericiiu  I'liysiciaus,  Wiisbington,  1888. 


Il  jt 


imi\- 


il&!"J 


m^ 


ari 


2  OSLER, 

(0  As  the  colorless  corpuscles  of  blood  and  mucus. 

(2)  The  connective-tissue  cells,  free  and  fixed,  within 
the  connective  tissue  proper,  or  forming  the  supporting 
framework  of  the  solid  organs. 

(3)  Cells  of  the  splee   ,  bone,  marrow,  and   lymph 

glands. 

(4)  The  vascular  and  lymphatic  endothelium. 

(5)  The  alveolar  epithelium  of  the  lungs. 

All  of  these  cells  possess,  in  a  greater  or  less  degree, 
the  power  of  taking  solid  particles  into  their  interior, 
virtually,  as  we  say,  of  eating  them. 

On  account  of  the  possession  of  this  property,  Metsch- 
nikoff  has  suggested  for  these  groups  of  cells  the  term 
plnv^ocytes,  as  expressiveof  their  most  distinctive  feature, 
and  for  the  process  in  general  the  term  phagocytosis. 

He  regards  this  function  as  a  property  handed  down 
from  the  primitive  unicellular  organism,  and  traces  in  an 
interesting  manner  the  evolution  of  cells  posse-;sing  it 
throughout  the  animal  kingdom  ;  attempting  to  show  a 
genettc  relation,  physiologically  at  least,  between  the 
free  living  rhizopods  and  the  cells  of  the  middle  germinal 
layer  of  the  higher  animals.  Not  a  little  of  the  attrac- 
tiveness of  Metschnikoft"s  views  is  derived  from  the 
glamor  of  evolution  thrown  over  them  by  thus  attributing 
the  retention  in  certain  cells  of  an  atavic  property  in  the 
highest  degree  useful  to  the  organism. 

I  shall  consider  first  the  action  of  these  phagocytes  as 
normal  phvsiological  factors  in  the  work  of  the  body  ; 
and,  secondly,  take  up  the  theory  that  these  bodies  pla\ 
an  essential  role  in  the  protection  of  the  organism  from 
the  invasion  of  specific  germs. 

And,  first,  two  illustrations  from  comparative  phy- 
siology to  indicate  the  important  part  assigned  to  phago- 
cytes in  certain  transformations  which  animals  undergo. 
In  the  development  of  the  frog,  the  removal  of  the  tail 
of  the  tadpole,  and  of  the  gills,  by  gradual  atrophy,  is 
effected,  according  to  Metschnikoff,  by  the  activity  of 


nd  mucus, 
ixed,  within 
;  supi)orting 

and  lymph 

um. 

less  degree, 
heir  interior, 

;rty,  Metsch- 
clls  the  term 
ctive  feature, 
gocytosis. 
landed  down 
1  tracf  5  in  an 
possessing  it 
ig  to  show  a 
between  the 
idle  germinal 
)f  the  attrac- 
,'ed   from  the 
lus  attributing 
roperty  in  the 

phagocytes  as 
of  the  body ; 
ic  bodies  plav 
rganism  from 

parative  phy- 
ned  to  phago- 
mals  undergo, 
val  of  the  tail 
lal  atrophy,  is 
the  activity  of 


ON     PHAGOCYTES,  o 

the  amoeboid  cells.  At  a  time  when  the  hind  legs  begin 
to  bud,  the  leucocytes  migrate  into  the  tail,  and  by  their 
phagocytic  action  remove  the  tissue,  fragments  of  which 
as  muscle,  bits  of  nerve  fibres,  etc.,  may  be  seen  in  the 
mterior  of  their  protoplasm.  The  gills  are  absorijed  by 
an  Identical  process.  In  the  transformadon  of  the  larva 
into  the  fly,  Kowalewsky'  has  shown  that  the  large  masses 
of  muscle  tissues,  so  abundant  in  the  larva,  and  other 
parts  unnecessary  in  the  matured  condition,  are  removed 
by  the  acuity  of  the  phagocytes. 

It  has  long  been  known  that  foreign  bodies,  such  as 
ligatures,  portions  of  dead  bone,  and  other  substances 
may  be  completely  removed  by  leucocytes.  Interesting 
as  IS  this,  and  bearing  directly  upon  the  question,  I  pro- 
pose to  hmit  myself  entirely  to  the  consideration  of  the 
two  aspects  above  referred  to. 

Nowhere  in  the  body  do  we  have  such  a  facility  for 
studying  the  action  of  phagocytes  as  in  the  organs  of 
respiration,  in  which,  with  the  cilia  of  the  bronchial 
mucosa,  they  share  in  the  work  of  cleansing  the  air-pas- 
sages ;  and  of  these  two  important  agencies  it  is  hard  to 
say  which  plays  the  more  important  part  in  the  expul- 
sion of  those  particles  of  foreign  matter  which,  in  cities 
at  least,  we  constantly  inhale.  There  are  several  groups 
of  cells  engaged  in  this  work  :  The  ordinary  mucus  cor- 
puscles ;  the  alveolar  epithelium;  the  connective  tissue 
elements  of  the  pulmonary  stroma,  and  the  leucocytes  of 
the  lymph  tissue  in  the  bronchial,  tracheal,  mediastinal 
glands. 

The  mucus  corpuscles,  which  in  health  are  derived 
largely  from  the  muciparous  glands,  and  in  intlammatory 
states  from  the  general  bronchial  mucosa,  arc  actively 
concerned  in  attacking  the  dust  which  reaches,  in  ordi- 
nary inspiration,  as  far  at  least  as  the  medium-sized  tubes. 

The  examination  of  the  morning  sputa  of  ,i  cigarette- 


■  'f 


11'^'^ 


I  Zeitschrlft  fur  vissensdwftliche  Zoblogie,  Bd,  45. 


tenderness  on  palpation.  fm^sa^Bmr- 

_  I  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
his  distressed  appearance.  He  lay  prup[)e(l  up  in  l)ed,  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature  100^     He  complained  of 

'  Read  by  title  at  the  meeting  uftlie  Association  of  American  Physicians,  Washington,  1888. 


4  OSLER, 

smoker,  or  of  a  person  who  has  been  exposed  to  a  dusty 
atmosphere,  shows  very  clearly  that  no  small  proportion 
of  the  carbon  grains  is  incliuled  within  protoplasm. 
The  free  granules  are  abundant,  '-ut  almost  every  leuco- 
cyte has  its  little  load  which  it  has  picked  up  on  its  road 
from  the  finer  tubes  to  the  trachea.  I  have  always  thought 
this  represented  a  neat  bit  of  economy  of  labor,  as  there 
can  be  no  question  that  it  is  easier  for  the  cilia  to  sweep 
half  a  dozen  angular  pardcles,  when  enclosed  m  a  cell, 
than  to  work  at  the  same  when  free.  In  all  probability, 
the  finer  particles  which  fall  upon  the  tracheal  or  the 
bronchial  membranes  are  gotten  rid  of  almost  entirely 
by  cells  and  cilia.  There  does  not  appear  to  be,  to  any 
great  extent,  penetration  of  pigment  granules  between 
the  ciliated  epithelium.  It  is  unusual  to  see  beneath  the 
tracheal  mucosa  any  collection  of  carbon  grains.  We 
do  meet  with  it  in  the  submucous  bronchial  tissue,  but 
the  active  vibratile  lining  seems  to  afford  a  tolerably  sure 
protection.  The  lymph  vessels  open  on  the  surface  in  the 
pseudo-stomata,  and  in  the  experimental  work  of  Arnold 
and  others,  leucocytes  carrying  black  grains  have  been 
seen  in  the  submucous  lymph  vessels ;  yet  the  process 
does  not  seem  to  go  on  to  any  great  degree. 

The  particles  which  reach  the  air  cells  find  no  active 
current  to  sweep  them  from  the  spots  on  which  they  iall. 
It  is  possible  to  conceive,  under  certain  conditions,  of 
the  air  cells  graduallv  filling,  were  it  not  for  the  activity 
of  phagocvtes,  derived  largely  from  the  alveolar  epithe- 
lium, which  stands,  as  it  were,  at  the  gateway  of  the 
lymphatic  circulation. 

The  cells  i.nin"  the  air  cells,  seen,  for  instance  by 
scraping  gently  the  cut  surface  t)f  an  cedematous  lung, 
look  as  flattened,  desiccated,  and  lifeless  as  do  the  scales 
of  the  scarf  skin.     But  appearances  are  deceptive  in  this 


I  Untersuchungcn  iiber   Stauljinlialatioii   und   Staubmetastase. 
Leipzig,  1885. 


ON    PHAGOCYTES, 


5 


I     I- 


Staubmetastase. 


case,  and  the  protoplasm  of  these  cells  is  not  onlv  active 
but  probably  vanes  much  in  shape  with  the  distention  or 
contraction  of  the  alveoli.    When  in  contact  with  liquids 
and  m  pathological  co.iditions,  thev  change  so  much  in 
form  that  I  hnd  it  often  a  difficult  lesson  to  teach  students 
familiar  with  normal  histology  only,  to  recognize  in  the 
large,  swollen  ovoid  cells  so  common  in  sputa,  alveolar 
epithelium.     .Moreover,   from  the  rapid  way   in    which 
they  may  be  desquamated,  there  must  be  ample  pro- 
vision for  their  rapid  restitution.     How  far  in  a  normal 
state  these  cells  take  part  in  the  work  of  cleansing  the 
lungs,  is  not  yet  definitely  settled.     In  the  voung,  thev 
do  not  often  appear  in  the  sputa,  except  when  there  are 
indications  of  catarrhal  changes,  but,  in  the  adult,  their 
presence  is  very  common.     It  is  rare  to  see  one  in  the 
sputa  of  a  hospital  patient,  which  has  not  brought  with  it 
a  load  of  carbon,  all  of  which  may  not  have  been  de- 
rived from  the  air  cells,  as  these  bodies  can  undergo 
amuiboid  changcb,  and,  like  the  leucocytes,  are  probably 
not  above  picking  up  a  grain   or  two  in  their  course 
toward  the  larynx.     In  cases  of  bronchial  catarrh,  and 
in  phthisis,  these  pigmented  cells  of  the  alveoli  may  be 
very  abundant,  producing  the   blackish  streaks  which 
may   be  seen  with  the  naked  eye.      When  these  cells 
have  undergone  the  myelin  degeneration  they  seem  no 
longer  capable  of  performing  scavenger  work. 

In  coal-miners,  or  even  in  stokers  and  coal-heavers, 
these  pigment-laden  cells  may  be  extraordinarily  abun- 
dant. It  is  not  only  when  the  patient  comes  direct  from 
the  mines,  or  from  the  coal-yards,  but  the  old  poitniiairei; 
which  haunt  in  such  numbers  our  city  hospitals,  expecto- 
rate for  months,  or  even  longer,  sputa  containing  tiie 
pigment-laden  alveolar  cells,  staining  the  entire  expecto- 
ration. So  persistent  may  this  be  that  the  process  may 
be  regarded,  not  simply  as  an  extrusion  of  the  daily  dole 
of  carbon,  but  as  a  definite  excretion,  if  we  may  so  use 
the  term,  of  particles  which  have  been  stored  up  in  pul- 
monary parenchyma. 


■I- 


tenderness  on  piilpation. 

I  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
Ins  distressed  appearance.  He  lay  propped  up  in  bed,  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature  100^     He  complained  of 

'  Read  by  title  at  the  meeting  uf  tlie  Assuciation  of  Amoricau  Physicians,  Wasliiogton,  1888. 


6  OSLRR, 

A  certain  proportion  of  the  inhaled  dust  particles 
escapes  the  mucus  cells  and  the  alveolar  epithelium  and 
penetrates  the  substance  of  the  lung,  entering  at  the  kitt- 
substanz  between  the  cells,  or  t'uough  the  pseudo-sto- 
mata  existing  in  the  alveolar  wall.  The  particles  of  coal- 
dust  iiave  such  sharp  angles  that  we  may  suppose  them 
capable  of  met  iianically  lacerating  the  delicate  alveolar 
cells. 

In  dweller-,  in  the  country,  as  wdl  as  in  wild  animals, 
breathing  an  air  comparatively  pure,  the  cilia  and  the 
phagocytes  in  the  air-passages  appear  cpiite  able  to  pre- 
vent access  of  the  carbon  grains  to  the  lung  tissue; 
whereas  in  the  dwellers  in  the  cides,  and  in  animals  kept 
in  confinement,  the  impurities  in  the  air  are  so  abundant 
that  these  agents  arc  insufficient,  and  sooner  or  later  the 
grains ;  penetrate  the  air  cells,  aided,  no  doubt  by  the 
movements  of  inspiration  and  expiration  ;  and  we  have 
the  well-known  marbled  or  car1)onized  organs  which  we 
sec  every  day  upon  the  post-mortem  table. 

When  the  particles  reach  the  lymph  spaces,  the  fixed 
and  free  connective  tissue  cells  of  the  stroma  join  actively 
in  the  work.  On  section  we  see  :..  the  alveolar  septa  large 
numbers  of  round  protoplasmic  bodies,  two  or  three  times 
the  size  of  colorless  blood-corpuscles,  which  are  usually 
packed  full  of  dark  grains,  A  certain  proportion  is  seen 
within  the  ordinary  connective  tissue  corpuscles,  and,  in 
addition,  there  are,  in  variable  numbers,  ordinary  leuco- 
cytes. But  even  these  forces  are  insufficient  to  meet  the 
constantly  advancing  stream  of  dust  particles.  The  des- 
tiny of  those  which  escape  the  phagocytes  in  the  alveolar 
stroma  has  been  accurately  followed  in  the  investigations 
of  Arnold  and  others.'  Entering  the  lymph  stream  they 
are  carried  first  into  the  lymph  nodules,  which,  in  the 
lungs  surround  the  bronchi  and  bloodvessels,  and  a  large 
number  becomes  fixed  in  the  cells  of  the  follicular  cords 
or  are  permanently  embedded  in  the  stroma. 


'  Vide  recent  work  of  Kleiner.    X'irchow's  Arcliiv,  Ud.  cxii. 


ON     PHAr.OCYTKS.  7 

As  they  pass  alon^r  the  1\  iiipli  cliannel^  into  the  inter- 
lobular septa  beneath  the  pleura,  a  still  further  nunibe 
lodKc  and  hecnnie  permanently  encldserl  in  the  stroma 
cells,  and,  linally,  the  remnant  pa!>s  into  the  larger  lymph 
channels  and  ultimately  lodge  in  the  bronchial  and 
tracheal  glands.  Here  the  lymph  and  stroma  cells  of 
the  follicular  cords  dispose  of  them  permanently.  That 
this  is  effected  in  great  part  by  the  phagocytes  is,  I 
thmk,  unquestioned,  A  scraping  from  anv  moderately 
pigmented  lymph  gland  shows  that  the 'chief  part  of 
its  carbon  load  is  warehoused  (so  to  speak)  in  proto- 
plasm, the  granules  lie  for  the  most  part  imbedded 
free  in  a  connective  tissue  matri.x.  Here  the  struggle 
is  piactically  over,  and  though  not  a  victorv,  vet  tlie 
compromise  which  has  been  made  is  the  best'  which 
could  possibly  be  effected.  The  sharji  irritating  particles 
have  been  placeil  in  position  in  which  they  could  do  the 
least  harm,  and,  though  not  expelled,  have  been  safely 
imprisoned. 

OncL  in  the  lymph  glands  of  the  bronchi,  it  is  thought 
they  never  reach  the  general  circulation,  but  it  has  l)een 
shown  of  late  years,  that  under  certain  circumstances  the 
carbon  particles  may  pass  the  bronchial  filters  and  spread 
far  and  wide  throughout  the  system.  Soyka's  remark- 
able case  in  which  undoubted  coal  particles  were  found 
in  the  tissue  of  the  spleen  and  of  the  liver  illustrates  what 
really  may  occur.  Weigert'  in  particular  has  called 
attention  to  the  frequency  with  which  in  the  spleen  and 
in  the  liver  carbonization  of  the  connective  tissue  occurs. 
He  states  that  it  results  whenever  densely  |)igmented 
bronchial  glands  form  close  adhesion  to  the  pulmonary 
veins,  through  the  walls  of  which  the  carbon  particles 
pass  and  so  reach  the  general  circulation.  I  would  not 
call  the  condition  common,  but  I  have  seen  at  least  three 
instances  at  the  Philadelphia  Hospital  in  which  the  ir- 

'   Kortschrittu  der  Me.licin,  Ikl.  i. 


:1 


;. 


;■  'i 


tenderne.'ss  on  palpation. 

I  saw  the  patient,  for  the  first  time  on  March  5th,  and  Avas  struck  with 
his  distressed  appearance.  He  hiv  pro[.pc-l  up  in  l)ed,  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature  100^     He  complained  of 

'  Read  by  title  at  tho  meeting  oftlie  Associatiou  of  Amorican  Physicians,  Waaliiugton,  1888. 


8 


OSLER, 


regularly  distributed  piHineiU  in  tiic  spleen  and  in  the 
liver  (in  the  latter  chiefly  alonj;  the  portal  canals)  was 
iind<)iil)ti.'(!ly  of  extraneous,  not  of  hicinic  orijjin. 

Tho  steps  in  this  |)rocess  described  may  be  followed  in 
the  lunjfs  of  any  town  dweller,  but  to  see  in  perfection 
the  remarkable  activity  of  the  pulmonary  phagocytes, 
one  must  study  the  early  stages  of  anthracosis,  particu- 
larly in  those  exceptional  rases  which  we  see  occasion- 
ally when  a  miner  has  been  killed  by  accident  or  dies  of 
acute  disease.  It  is  not,  I  think,  too  much  to  say  that 
the  larj,'cr  part  of  the  pi^'mi  '  contained  in  1un^;s  almost, 
if  nut  ipiitc,  black,  is  enclosed  in  [.otoplasmic  cells. 
Here  too  the  invading  particles  are  more  forniidable  and 
not  so  readily  dealt  with;  yet  one  frequently  linds  long 
irregular  bits  completely  encircled  by  a  film  of  proto- 
plasm which  the  phagocyte  has  stretched  to  the  utmost, 
just  as  we  may  see  an  amceba  extend  alon^  tlie  whole 
length  of  one  of  the  short  rod-like  diatoms. 

I  know  f)f  nothing  which  illustrates  better  the  remark- 
able anueboid  properties  of  human  protoi)lasm  than  a 
slide  prepared  from  the  scraping  of  such  a  lung,  or  of 
the  black  juice  pressed  therefrom.  Scarcely  a  leuco- 
cyte can  be  seen  which  has  not  been  at  work,  and  many 
of  the  larger  cells  have  the  protoplasm  stuffed  to  the  full 
with  carbon  grains.  Only  in  the  work  of  the  pond 
amoebae  preying  amongst  desmids,  diatoms,  and  algie 
can  we  see  such  better  illustrations  of  active  work. 
There  is,  of  course,  this  difference,  that  the  amoeba  eats 
to  live,  and  so  far  as  I  know  never  loads  its  protoplasm 
with  useless  ■^^'■ff.  The  body  phagocytes  take  anything, 
never  exer..  a  selective  powers.  The  particles  which 
gain  entra'  .t  j  the  lungs  may  be  far  too  large  for  a 
sintrle  phago  ;  ^e  to  attack  successfully.  I  have  sketches 
showing  rod  like  particles,  the  ends  of  which  appear 
enclosed  in  protoplasm  of  a  dumb-bell  shape ;  while  in 
one  instance  not  only  were  the  ends  enclosed,  but  the 


ON    PHAGOCVTES. 


central  portion  was  completely  enveloped  l.v  tin   thud 
leucocyte. 

A  physiological  process  in  which  pha<(ocytcs  play  a 
ieadinjr  roli\  is  the   removal  and  diKinteKiatioii   of  the 
red  blood-corpuscles  which  have  lived  their  life  and  are 
no   longer  tit  for  work.     The  cells  coiitainim;  the  red 
blood-corpuscles,  which  arc  found  in  the  hone  niar.ow 
and  in  the  splef  i,  ^   wever  much  opinion  may  differ  as 
to  their  mod     of  oii;.,  •.   cannot,  I  think,  be  rc<,Mrded  in 
any  other  1  ;hf  'han  ;.     phagocytic  elements  with  this 
definite  fun-  Uo,i      'i'hcy  ;.\ist  normally  in  the  red  mar- 
row, and  in  i.S^:   ipieen    ind  we  may  recojini/e  (i )  cells 
which  appear  t       ,-,  x.um.  their  size  and  shape,  elements 
of  the  pulp  and  ,;j)  cells  which  belong  to,  or  are  derived 
from  the  endothelium  of  the  capill.uies,  and  (3)  the  (  ulls 
of  the  stroma.     The  gradual  production  of  the  pigment 
in  this  way  has  been  so  often  described,  and  is  so  well 
known  that  I  need  not  now  dwell  upon  it.     In  certain 
morbid  conditions  we  see  this  process  widely  extended, 
and  we  find  cells  containing  red  blood-corpuscles  in  the 
liver,  in  the  lymph-glands,  even  in  the  blood  itself;  and 
particularly  is  this  the  casein  those  states  associated  with 
rapid  blood  deterioration   and  destruction,  as  in   acute 
fevers,  when  these  bodies  may  be  enormously  increased. 
In  certain  forms  of  an.emia  so  abundant  are  they  in  the 
bone  marrow  and  in  the  spleen  that  they  have  been  re- 
garded as   directly  concerned  in  the  widespread  hicmo- 
phthisis. 

The  observations  of  Quincke'  and  his  pupils  have 
shown  that  the  liver  is  the  chief  seat  of  blood  destruction 
in  pernicious  anicmia,  but  the  totally  different  ippearance 
presented  by  this  organ,  even  in  long-standing  cases,  to 
that  met  with  in  malaria,  shows  a  radical  difference  in 
the  nature,  possibly  in  the  seat  of  the  hicmolytic  action. 
In  the  former  case,  the  pigment  is  chiefly  in  the  liver 


k(J 


ij 


<  rHnit.-M'hcs  Ardiiv  f,  kliii.  Med.,  Bds.  xxv.,  xxv 


XXXIL,   XXXMI, 


tenderness  on  palpation.  *«»,«,. :^. 

I  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
Ills  distres.sed  appearanee.  He  hiy  ])n)ppe(l  up  in  bed,  had  sligat 
dyspnani,  dry  tongue,  pulse  100,  temperature  100^     He  complained  of 

1  Read  by  title  at  tho  meeting  nftlie  Association  of  American  Pliyaicians,  Washington,  1888. 


llNIWf!,.'!, 


.\>'. 


lO 


OSLER, 


cells  ;  in  the  latter,  in  the  stroma  and  about  the  blood- 
vessels. We  cannot  from  this  regard  pernicious  anaemia 
as  an  hepatic  disorder.  The  liver,  probably,  makes  the 
best  disposal  it  can  of  an  abnormally  large  amount  of 
coloring  matter,  which  is,  I  should  suppose,  not  brought 
to  it  in  the  same  form  as  in  malaria,  but  rather  in  a  form 
similar  to  the  raw  material  of  the  bile  pigment,  which 
would  account  for  the  active  participation  of  the  liver 
cells.  The  deep  beefy-red  color  of  the  muscles  in  per- 
nicious anaMTiia  also  tells  of  an  abnormally  large  quan- 
tity of  coloring  matter  at  the  disposal  of  the  tissues. 

In  chronic  emphysema,  in  mitral  obstruction,  and  in 
all  affections  in  which  the  circulation  within  the  lungs  is 
permanently  embarrassed,  the  condition  of  brown  indura- 
tion which  ensues  affords  a  very  beautiful  illustration  of 
the  same  process.  The  blood  corpuscles  by  diapedesis 
reach  the  stroma  of  the  air  cells,  where  they  are  seized 
upon,  just  as  are  coal  particles,  by  the  connecdve-tissue 
cells,  and  are  gradually  converted  into  a  pigment  which 
retains  for  a  long  time  its  brownish  tint,  but  which  may 
ultimately  become  black. 

Neumann,  in  a  recent  paper,'  doubts  whether  the 
brown  induration  of  the  lungs  is  really  the  result  of  the 
ingestion  of  the  red  blood-corpuscles  by  the  stroma  cells. 
He  holds  that  in  many  instances,  at  least,  structures 
within  the  corpuscles,  which  resemble  so  closely  the  red 
blood-disks,  are  in  reality  only  pigm.ent  forms  having 
the  size  and  color  of  the  red  blood-cells.  We  certainly 
see  structures  within  the  cells  which  cannot  possibly  be 
mistaken  for  anything  but  red  blood-corpuscles,  and,  I 
think,  the  expert  eye  can  usually  discriminate  between 
such  and  the  round  aggregations  of  pigment,  however 
d(  -eptive  may  be  their  form  and  color. 

Phagocytosis  has  been  studied  in  the  process  associ- 
ated with  absorption  of  extravasated  blood.     Langhans 


Virchuvv's  .Aixliiv,  Bd.  no. 


ON    PHAGOCVTKS. 


II 


Lit  the  blood- 
ious  anaemia 
1,  makes  the 
e  amount  of 

not  brought 
ler  in  a  form 
ment,  which 

of  the  Hver 
scles  in  per- 
'  large  quan- 

tissues. 
tion,  and  in 
1  the  lungs  is 
rown  indura- 
Uustration  of 
)y  diapedesis 
;y  are  seized 
lective-tissue 
^ment  which 
t  which  may 

whether  the 
result  of  the 
stroma  cells. 
3t,  structures 
osely  the  red 
Drms  having 
vVe  certainly 
t  possibly  be 
jscles,  and,  I 
late  Ijetween 
;nt,  however 

ocess  associ- 
.     Langhans 


was  the  first  to  show  that  blood  effused  into  the  tissue 
did  not  simply  disintegrate  and  disappear,  but  that  the 
connecdve  tissue  elements  were  actively  at  work,  and  that 
no  small  proportion  of  the  colored  corpuscles  was  ulti- 
mately taken  into  the  interior  of  their  protoplasm.  This 
has  been  amply  confirmed,  and  I  think  th^re  can  be  no 
question  as  to  the  fact ;  but  observers  ar'  by  no  means 
unanimous,  however,  whether  the  phagocytes  are  essen- 
tial in  the  process.  Probably  in  large  extravasations 
only  the  peripheral  parts  are  dealt  with  in  this  way 
The  fi.\ed  connective-tissue  cells  with  migrated  leuco- 
cytes all  share,  I  believe,  in  the  process.  It  must  not 
be  forgotten,  as  Neumann  has  pointed  out,  that  pigment 
granules  in  the  interior  of  the  cells  may  resemble  blood 
corpuscles  very  closely.  However  this  may  be  there 
can  be  no  doubt  that  the  cells  are  concerned  'in  the 
transformation  of  the  haemoglobin,  whether  they  take  it 
up  with  the  corpuscles  or  after  it  is  diffused  from  them 

Remarkable  differences  e.xist  in  the  final  transforma- 
tion of  the  haemoglobin,  resulting  in  the  formation  of 
two  pigments,  ha:matoidin,  which  develops  chiefly  in  the 
central  parts  of  the  extravasation,  and  an  albuminate  of 
iron,  hajmosiderin  (Neumann),  which  is  formed  at  the 
Iioundaries  of  the  clot  and  wherever  the  coloring  matter 
comes  in  contact  with  the  tissues.  That  this  difference 
is  related  in  some  way  to  the  influence  of  the  cells,  is  in 
the  highest  degree  probable,  though  Neumann  is  not  in- 
clined, from  his  observations,  to  attribute  an  important 
action  in  this  respect  to  either  the  fixed  or  wanderino 
connective  tissue  elements.  The  question  is  one  to 
which  a  few  years  ago  I  gave  some  studv  in  connection 
with  development  of  cells  containing  red  blood-corpus- 
cles, and  I  was  much  impressed  with  the  truth  of  Lang- 
hans' statement  as  to  the  frequency  and  numbers  of 
these  structures  in  the  vicinity  of  extravasations  of  all 
kinds. 

In   the  intestinal  canal  the  leucocytes  assist,  to  s.nne 


i 


■  ) 


\i 


tenderne.ss  on  piilpation. 
1  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 


Ins  ( 


ilistressed    appcanince.       He   hiy   jtroppcd    up  in   bed,  had  slight 
dys])nani,  dry  tongue,  piiL^e  100,  temperature   100  \     He  complained  of 


Read  by  title  ut  th«  meeting  .jftlie  Assuciatiuu  of  A 


moricaii  Pliy«icinUB,  Wiisliingtoii,  1888. 


12 


OSLER, 


extent  M  least,  in  the  absorption  of  fat.     Schaefer's  ob- 
servations upon  this  point'  show  very  clearly  that  during 
digestion  the  amoeboid  cells  of  the  mucous  coat  become 
filled  with  fat  globules.     How  these  are  obtained  we  do 
not  as   yet  know  clearly.     Whether  the  fat   penetrates 
between  the  epithelial  cells,  or  whether  the  leucocytes 
pass  up  between  the  cells  reaching  to  the  surface  and 
here  secure  the  fat,  has  not  been  definitely  determined; 
though  from  the  presence  of  an  occasional  cell,  or  even 
a  nest  of  cells  between  the  cylinders,  the  latter  view  is 
probably  the  correct  one.     The  leucocytes  pass  to  the 
central  lymph  vessels,  where  they  disintegrate,  and  dis- 
charge their  load  of  fat  granules  which  has,  meanwhile, 
in  the  protoplasm  of  the  cell,  been  broken  up  into  finer 
particles,  which  form  the  so-called  molecular  base  of  the 
chyle.     Possibly,  too,  the  leucocytes  may  take  up  other 
ingredients.     It  is  interesting  to  note  that  in  many  of  the 
lower  animals  the  amoeboid  cells  of  the  endoderm  possess 
an  active  digestive  function.    The  observations  of  Parker 
and  Lankester  appear  to  confirm  fully  the  researches  of 
Metschnikoff  on  the  phenomena  of  intercellular  diges- 
tion in  invertebrates. 

So  far,  we  have  been  dealing  exclusively  with  the 
action  of  phagocytes  under  normal  conditions.  And  it 
is  clear  that  these  mesodermic  cells  have  important  func- 
tions throughout  the  life-history  of  the  organism.  Not 
only  in  the  early  steps  in  the  development  of  the  blasto- 
derm do  we  see  them  actively  at  work,  but  in  various 
stager,  of  development,  particularly  in  that  of  the  bone, 
their  action  is  of  the  first  importance.  In  the  mature 
body  we  have  seen  that  in  the  lungs,  in  the  intestines, 
and  in  the  blood-making  organs,  the  phagocytes  have 
most  essential  functions ;  but  the  question  of  chief  interest 
to  day  relates,  not  so  much  to  this  normal  process  about 


1  Monthly  International  Journal  of  Anatomy  and  Physiology, 
1885. 


lefer's  ob- 
liat  during 
at  become 
ned  we  do 
penetrates 
leucocytes 
urface  and 
:;termined ; 
ill,  or  even 
tter  view  is 
lass  to  the 
;e,  and  dis- 
Tieanwhile, 
p  into  finer 
base  of  the 
:e  up  other 
iiany  of  the 
;rm  possess 
IS  of  I'arker 
:searches  of 
iular  diges- 

[y  with  the 
ns.  And  it 
ortant  func- 
.nism.  Not 
f  the  bhisto- 
;  in  various 
if  the  bone, 
the  mature 
e  intestines, 
ocytes  have 
:hief interest 
rocess  about 

d  Physiology, 


ON    PHAGOCyTES. 


13 


which  there  has  never  been  much  doubt,  as  to  the  sup- 
posed part  which  these  cells  take  in  protecting  the  body 
against  the  invasion  of  parasites. 

The  theory 'elaborated  by  MetschnikotT  had  be^n 
hinted  at  i)y  many  previous  observers,  but  to  him  is 
undoubtedly  due  the  credit  of  bringing  it  into  promi- 
nence, and  of  doing  in  connection  with  it  a  very  large 
amount  of  interesting  work.  It  must  be  allowed  that 
he  came  to  his  task  ueil  prepared.  Many  of  us  can 
look  back  with  pleasure  to  his  brilliant  investigations 
upon  the  intracellular  digestion  m  the  Planari;e"ind  in 
Sponges,  carried  on  largely  at  the  Naples  Marine  SMtion  • 
investigations  the  truth  of  which,  so  far  as  I  know,  has 
not  been  controverted.  Following  these  studies,  directly 
in  the  same  line,  was  his  interesting  research  into  the 
methou  of  the  absorption  of  the  tail  of  the  tadpole,  al- 
ready referred  to,  in  which  he  appears  to  have  denion- 
strated  that  the  atrophy  of  this  organ  results  in  reality 
from  the  active  removal  of  the  fragments  of  the  tissue  by 
leucocytes. 

So  f;ir  the  work  was  biological,  and  had  no  direct 
bearing  u])on  the  phenomena  of  disease  further  than 
that,  in  the  latter  illustration,  it  bore  out  the  well-known 
fact  of  the  absorption  by  leucocytes  of  foreign  bodies 
placed  within  the  tissues.  In  1884,  in  the  96th  vol.  of  Vir- 
chow's  Archiv,  he  published  a  paper'  which  arrested  the 
immediate  attention  of  students  in  parasitology.  It  is  now 
too  old  a  story  to  narrate  at  length  ;  it  will  be  sufficient  to 
remark  that  in  the  daphnia,  the  common  water-flea  of 
the  aquarium,  he  had  studied  the  reladon  of  the  leuco- 
cytes to  a  fungus  with  which  these  insects  are  prone  to 
be  infected.  1  he  phagocytes  attack  the  fungi  which  enter 
the  body  cavity  from  the  intestines,  and  pracdcally  eat 
them,  enclosing  them  in  protoplasm.  Where  one  cell  is 
insufficient,  several  combine  to  enclose  the   spores  in 


'   Ueber  cini!  Sposspilzkraiikheit  der  D, 


ipliinon. 


I 


tenderness  on  pulpiUion. 

I  saw  the  patient  for  the  first  time  on  Marcli  5th,  and  was  struck  with 
Ills  <listres8e(i  appeanuiee.  Ho  hiv  propfied  up  in  l)0(l.  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature   100^     Jle  complained  of 

>  Read  hi  title  iit  th«  meetiiitj;  ol'llie  Association  of  Americiin  Pliysiciaus,  Wiisliiiigton,  1888. 


14 


OSLER, 


large  plasmodia-like  aggregations— giant-cells.  If  tlie 
invasion  was  in  such  large  numbers,  and  the  activity  of 
the  fungus  so  great  that  conidia  were  formed,  the  resisting 
forces  were  insufficient,  victory  remained  with  the  enemy, 
which  meant  the  death  of  the  daphnia.  Of  lOO  insects 
studied,  73  became  infected,  of  which  59  -ecovered  and 

14  died. 

Following  this  line,  Metschnikoff  proceeded  to  study  the 
relation  of  leucocytes  to  anthrax  bacilli,  to  the  micro- 
organisms of  erysipelas,  and  to  various  other  affections. 
He  likened  specific  inflammation  to  a  warfare  in  which 
the  invading  army  is  represented  by  microorganisms,  and 
the  resisting  forces  by  the  leucocytes.     Even  in  details 
the  analogy  was  maintained.     Notice  of  the  arrival  of 
the  invaders  was  telegraphed,  so  to  speak,  by  the  vaso- 
motor nerves  ;  the  line  of  communication,  the  avenues  of 
mobilization,  were  represented  by  the  bloodvessels.    The 
aim  of  the  invader  is  to  secure  the  territory,  to  multiply 
rapidly,  to  live  at  the  expense  ^f  his  host,  and  to  manu- 
facture and  circulate  substances  injurious  to  him.     The 
aim  of  the  resisting  forces  is  to  encircle  the  enemy,  inclose 
him,  digest  him,  and  render  in  inert  in  battle.     Many 
phagocytes  die  in  the  process     .vi,  if  in  large  numbers, 
the  heaps  of  the  slain  represen   ^us  ;  an  abscess  is  a  bat- 
tleground densely  packed  wim  dead  bodies.     If  victory 
remains  with  the  invaders  the  organisms  pervade  the 
affected  part,  multiply,  and  induce  conditions  incompat- 
ible with  the  life  of  the  part,  or  perhaps  with  the  life  of 
the  entire  organism.     If  the  battle  is  with  the  host,  the 
parasites  are  destroyed,  perhaps  not  without  loss,  but  the 
normal  state  is  gradually  restored.     Practically,  on  this 
theory  each  organism  is  regarded  as  possessing  a  stand- 
ing ai-my  composed  of  mesoblastic  cells,  capable  of  rapid 
reprouiiction   and  rapid   concentration,   6ne  important 
function  of  which  is  to  protect  the  organism  against  de- 
structive agencies  invaJing  it  from  without.     Certainly 
a  most   attractive  theory,  fully  deserving  the  attention 


(     ! 


ON    I'HAGOCYTES. 


15 


which  It  has  aroused.  On  the  one  hand  widely  accepted 
on  the  other  bitterly  assailed,  the  question  is  as  yet  far 
from  settled,  and  to  the  position  in  which  it  stands  I  pro- 
pose briefly  to  refer,  and  then  to  offer  some  results  of  my 
own  observations  upon  a  disease  in  which  special  facih- 
t;es  exist  for  the  study  of  the  problem. 

Metschnikoff  has  studied  a  number  of  diseases,  ery- 
sipelas, anthrax,  relapsing  fever,  and  tuberculosis,  with'a 
view  of  finding  facts  in  support  of  this  thcorv,  and  his 
communications  within  the  past  four  years  have  been 
numerous  and  elaborate.'  Thev  have  been  so  widely 
abstracted  and  so  often  referred  to  that  ]  shall  not  occupy 
your  time  by  entering  into  details,  but  will  briefly  indi'- 
cate  the  chief  points  upon  which  he  lays  special  stress  in 
these  difierent  affections,  and  note  certain  of  the  observa- 
tions which  have  been  made  by  other  workcs. 

In  erysipelas  the  cocci  are  attacked  first  by  the  leuco- 
cytes filling  the  lymph  spaces,  which  rapidly  proliferate 
and  actively  eat  the  microorganisms.  Not  alone  do 
the  colorless  corpuscles  act  as  phagocytes,  but  the  fixed 
connective  tissue  cells  assist  in  an  important  manner. 
In  cases  of  recovery  he  found  that  behind  the  advancing 
cocci  the  leucocytes  were  crowded  with  parasites 
which  showed  evidences  of  digestion  and  destruction. 
The  connective-tissue  do    not    appear  to    attack 

the  cocci,  but  are  chiefty  concerned  with  the  absorption 
of  the  inflammatory  exudate,  even  taking  up  the  leuco- 
cytes whicli  have  died.  In  fatal  cases  there  was  enormous 
development  of  micrococci,  the  majority  of  which  lay 
free  in  the  tissues  not  enclosed  in  the  phagocytes.  Inoc- 
ulations with  erysipelas  cocci  in  white  rats  confirm  tiiese 
observations  made  in  man.  The  leucocytes  attack  the 
parasites,  whicli  undergo  rapid  degeneration  in  the  proto- 
plasm. The  larger  connective  tissue  cells,  macrophages 
did  not  attack  the  cocci.     Metschnikoff  recommends'ex- 


'  Publislied  cliinly  in  Virchow's  Aichiv. 


ilm^ 


!: 


tenderness  on  piilpation. 

I  saw  tlio  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
Ins  distressed  apiiearance.  He  lav  prop|)c<I  up  in  bed,  had  slight 
dyspnoea,  dry  tongue,  pulse  100,  temperature  100 '.     He  complained  oi' 

'  Head  by  title  at  th«  moetiiig  .iltlie  .\s8ucii\tiun  of  AiiuTiciui  I'liysieians,  WiisUiugtun,  1888. 


Nil 


i6 


o  s  r.  E  K  . 


pvrimcnts  upon  these  annnals  nv.u.  the  ..rys.pehis  co<  i 
as  an  especially  favorable  field  in  y.hich  to  study  the 
struir>Tle  between  tVie  cells  and  bacteria. 

In  uUhrax  Mrt-  ■  snikoff  has  studied  the  relation  of  the 
phagocytes  to  bacilii  introduced  into  fogs,  which,  as  is 
well  known,  posses,  immunity  at  the  ordina.)-  U:nii>era- 
ture,  bu.   succumb  -vhen  the  a>niperature  is  raised.     A 
graft  of  a  piece  of  anthraN  tis-ie  under  ine  skrn  of  a  Irog 
is  within   from    fifteen  to  tw,- vy  hou-s   sunounded  by 
leucocytes,  which  take  up  many  baciil..     According  to 
K(.ch   th' ,'  inav  grow  inside  the  cells  and  even  burst 
them,' but  Metschnikoff  holds  that  the  anthrax  filaments 
do  not  develop  within  the  cell,  but  are  gradualy  de- 
stroyed by  them,  and  that  th>.  Is  the  reason  why  the  frog 
at  an  ordinary  temperature  recovers.     In  the  heated  frog 
the  bacilli  rapidly  develop  aiul  the  efforts  of  the  leuco- 
cytes  proving  insufficient,  tht    .animal   dies;    not,  it  is 
asserted,  from  any  inactivity  on  the  part  of  the  leucocytes 
but  because  the   bacilli  secrete  a   liquid  which  protects 
them  from  attack. 

In  Haumgarten's  criticism'  he  rc'ates  some  experiments 
^vith  the  anthrax  bacilli  which  directly  antagonize  these 
observations.  Pigeons  do  not  die  when  inoculated  with 
anthrax  and  he  found  that  the  bacilli  injected  degene- 
rate in  precisely  the  same  way  in  these  creatures  as  ^vhen 
in  distilled  water ;  only  here  and  there  did  the  leucocytes 
contain  the  rods. 

He  found  that  in  frogs,  though  the  bacilli  are  eaten 
by  the  leucocytes  inversely  to  the  degree  of  heat  to  which 
the  animal  is  exposed,  there  is  never  total  destruction  of 
the  bacilli  by  the  phagocytes.  .  ,   ,         ,.      ,, 

Hess'^  has  performed  experiments  which  bear  directly 
upon  these  points.  Anthrax  cultures  in  Zeigler's  glass 
chamber,  inserted  beneath  the  skin  in  animals  not  very 

1  Zeitschrift  f.  klin.  Medicin,  Bd.  xv.  Hft.  I  u.  2. 

2  Virchow,  Archiv,  Bd.  109. 


ON     PHAGOCYTKS. 


17 


susceptible  to  the  disease,  as  cio^'s  and  birds,  showed 
active  migration  of  the  leiu  ■  -  ytes  into  the  chanilier  which 
appear  to  attack  the  bacilli  and  to  destroy  them.  These 
very  striking  experiments  certainly  indicate  what,  of 
course,  is  well  known,  a  high  degree  of  activity  on  the 
part  of  the  leucocytes,  finding  their  way,  as  they  do, 
into  the  chamber  closed  at  all  points  except  one  nar- 
row orifice.  But,  as  Hess  says,  it  is  a  question  whether 
the  disintegration  in  the  cells  necessarily  means  destruc- 
tion by  the  cells. 

In  relapsinj^  fever  Metschnikofif  states  that  the  spirilli 
are  not  attacked  by  the  leucocytes  in  the  blood  but  are 
destroyed  only  in  the  spleen.  In  the  artificially  produced 
disease  in  monkeys,  he  finds  abundant  inclusion  of  the 
spirilli  in  the  phagocytes  of  the  spleen  during  the  period 
of  the  rise  in  temperature  before  the  crisis.  This,  how- 
ever, may  simply  mean  that  the  spirilli,  most  of  which 
gradually  disappear  from  the  blood  at  the  crisis,  have 
lived  their  life  and  are  about  to  die,  and  in  this  state  arc 
taken  up  by  the  normal  splenic  phagocytes,  just  as  are 
the  effete  red  blood-cOrpuscles.  He  explains  the  recur- 
rence of  the  second,  or  even  of  the  third,  attack  of  the 
fever  by  supposing  that  certain  spirilli  remain  alive  after 
the  crisis  and  start  afresh  a  new  generation,  which  is  not 
retarded  in  its  growth,  as  the  phagocytes  are  too  busy  in 
digesdng  the  spirilli  which  they  had  eaten  during  the 
former  attack. 

An  interesting  study  of  phagocycosis  has  been  made 
by  Laehr,  a  pujjil  of  Ribbert,'  who  has  studied  the  effect 
of  injection  into  the  lungs  of  rabbits,  through  the  trachea, 
of  staphylococcus  pyogenes  aureus.  Within  a  few  hours 
the  cocci  are  almost  all  to  be  seen  within  the  alveolar 
epithelium,  and  in  the  leucocytes,  which  latter,  in  the 
course  of  a  few  days,  disappear  from  the  alveoli  and  pass 
into  the  bronchi.     Meanwhile,  the  alveolar  epithelium 


■!■      '.f 


'  Alistracted  by  Bitter;  Zeitschrift  f.  Hygiene,  Bd.  4. 


tenderness  on  palpation. 

I  saw  tlie  patient  for  tlie  first  time  on  March  r)th,  and  was  struck  with 
liis  distressed  appearance.  He  lay  i)r()ppe(l  up  in  bed,  had  slight 
•lyspnoea,  dry  tongue,  pulse  100,  temperature  100^     He  complained  of 

'  Ueiul  by  title  at  the  meeting  ultlie  Association  of  Amorimn  Pliysicians,  Wiisliington,  1888. 


:i 

ll 

i      . 

■ 

•      ■ 

VM 

I 

ll 

■     S 

i^^l 

1      '            , 

i   ■     .  - 
1    i      * 

1 

i8 


OSLER, 


proliferates,  causing  i  catarrhal  intlammation.  Within 
the  first  week  the  cells  contain  many  cocci,  which  gradu- 
ally become  less  numerous,  and  in  the  second  week  en- 
tirely disappear.  He  looks  upon  this  as  a  confirmation 
of  Metschnikoff's  views. 

In  a  second  investigation,  Hess'  has  studied,  in  rab- 
bits and  in  cats,  the  relation  of  the  leucocytes  to  the 
staphylococcus  aureus  inoculated  in  the  cornea.  At  first 
there  is  marked  increase,  which  leads  to  an  acute  inflam- 
matory process  in  the  neighborhood  of  the  cocci.  The 
leucocytes  increase  rapidly,  and  within  two.or  three  days 
almost  all  of  the  cocci  are  within  cells.  In  cases  which 
recover,  by  the  sixth  day  no  cocci  are  found.  When  the 
process  does  not  result  in  healing,  the  phagocytosis  is 

slight.  1  •    1  t 

Baumgarten  states'^  that  experiments  made  in  his  lab- 
oratory do  not  confirm  these  results  of  Hess. 

Ribbert,  iii  his  study  on  the  destruction  of  pathogenic 
bacteria   in  the  body,  supports   Metschnikoff's'  views. 
He  found,  after  injection  of  the  spores  of  Aspergillus  and 
Mucor,  that  they  collected  in  the  organs  of  the  exper'- 
mental  animals,  particularly  in  the  liver  and  lungs,  and 
that  within  a  few  hours  after  injection  they  were  sur- 
rounded  by   leucocytes,  which   cither  completely  pre- 
vented or  restricted  the  growth  of  the  germs.     Injections 
in  very  large  quantities  might  not  be  sufficient  to  hinder 
the  growth  of  the  parasites,  and  the  animal  died.    In  the 
lungs  and  in  the  liver  the  phagocytes  are  much  more 
active  than  in  the  kidneys.    Precisely  similar  occurrences 
were  found  where  the  spores  were  injected  into  the  ante- 
rior chamber,  and  it  is  worthy  of  note  that  he  found  on 
the  anterior  surface  of  the  iris,  in  the  neighborhood  of 
the  pupil,  the  phagocytes  much  more  active  and  the  dis- 


1  Virchow's  Archiv,  I5d.  no 
»  Jahresbericht,  Bd.  3. 
•i  Abstracted  by  Bitter 


Zeitschril't  fiir  Hygiene,  Bd.  4. 


ON     PHAf'.OCYTES. 


19 


jff's^  views. 


integration  of  tlic  spores  imirli  more  m;irked  than  in  tlie 
posterior  part  of  the  iris  in  contact  with  the  lens.  Rib- 
bert  holds  that  the  destructive  influence  of  the  leucocytes 
is  exercised  chiefly  by  their  preventing  access  of  nourish- 
ment to  the  spores  (particularly  of  oxygen),  and  in  favor- 
ing, also,  an  accumulation  about  them  (if  destructive 
metabolic  products.  He  regards  the  fi.\ed  connective- 
tisHie  cells  of  the  liver,  and  the  giant  cells  which  develop 
in  the  liver  and  in  the  lungs,  as  the  most  important  agents 
in  the  final  destruction  of  the  spores. 

As  we  might  suppose,  the  \  lews  of  .Metschnikoff  have 
met  with  sharp  criticism  in  many  quarters,  and  from  no 
one  more  ably  and  at  greater  length  than  from  Baum- 
garten.'  While  not  denying  that  the  leucocytes  eat  the 
bacteria,  he  claims  that  the  process  is  by  no  means  uni- 
versal, and  is  carried  on  so  unequally,  that  we  can 
scarcely  speak  of  an  active  warfare  waged  against  the 
parasites. 

As  a  specially  weak  point,  he  alludes  to  the  powerless- 
ness  of  the  phagocytes  in  the  Daphnia  disease  so  soon 
as  the  conidia  are  formed  from  the  sjiores. 

In  relapsing  fever,  the  freedom  from  attack  which  the 
spirilli  enjoy  in  the  blood  is  urged  strongly  against  the 
phagocytic  theory.  The  fact  that  spirilli  are  found  in  a 
number  of  cells  of  the  spleen  toward  the  crisis  simply 
means  that  the  phagocytes  of  this  organ  behave  to  them 
as  to  other  foreign  bodies.  Probably,  too,  the  spirilli  be- 
gin at  this  time  to  lose  their  vitality,  as  is  shown  by  their 
less  active  movements,  and  are  then  readily  taken  up  by 
the  splenic  leucocytes  in  a  manner  precisely  similar  to 
effete  blood  corpuscles. 

In  erysipelas,  Baumgarten  criticises  the  position  in 
which  Metschnikoff  finds  the  parasites,  namely,  in  the 
second  zone,  behind  the  advancing  cocci,  as  conclusively 
showing  that  they  are  not  fighters  of  the  battle — not,  as 


*  Loc.  cit. 


tenderness  on  palpation. 

I  saw  the  patient  for  the  first  time  on  March  5th,  and  was  struck  with 
liis  distressed  appearance.  He  hiy  prop[)e(l  up  in  \m\,  liad  slight 
dyspnoea,  dry  tongue,  pulse  IC  '.  temperature  100''.     He  complained  of 

'  Road  by  titia  at  the  meetlug  of  tlie  Associ    ^un  uf  A.rr  ric  au  Physicians,  Washington,  1888. 


if^ 


11 


y/.' 


Ih 


I 


Ml 

'     '1 

i    .      if 

V 

' 

1 

0,                                            «f 

1  ■               1 

a 

I 


2o  O  S  L  E  R , 

he  expresses  it,  "the  heroes  of  the  day,  but  the  hyenas 

"''?heS;vntion.'>f-'^ristmas-Derkinck-Hoh..feUl>are 

also  dire,  .  ,  opposed  to  che  th.  ory  of  Ph.'^gojy;"^';-       "^ 
finds  in  anthrax  experiments  that  very  few  of  the  bac.lh 
:;  taken  up  by  the' leucocytes.     In  rats  they  degenera  e 
within  two  or  three  days  after  inoculation,  and  for  the 
most  part  outside  of  the  cells.     He  holds  d.at  pus  orma- 
tion  is  a  conservative  reaction  against  the  Penetration  of 
the  bacterial  germs,  but  that  the  neutralization  o     he 
action  of  microorganisms  depends  much      ...e  .  n  the 
chemico-biological  relations  of  the  tissues  than  on  .uy 
propertv  of  the  cells  to  destroy  them  by  'f  >^>f  "•     "'^ 
lievv  in  fact,  approaches  thai  of  Ribbert  already  lefer red 
to  Tn  ascribing  the  limitation  of  bacterial  growth  to  nutn- 
\we  change:    particularly  to  the  restriction  of  oxygen, 
rather  than  ..  any  phagocytic  action  of  the  ceU^. 

In  Klugge-s  laboratory,  observation.  1;  •  '^^^^^^'  .™^°; 
byBitterand  bv  N  .ttall,-^ of  San  Francisco,  which  d. rectly 
contradict  those  of  Metschnikoff.     ^utud  s  eUbora  e 
experiments  appear  to  show  conclusively  that  the  destruc- 
tion of  the  bacilli  in  the  living  body  is  not  effected  b>  the 
nhatrocvtic  action  alone.                          , 
'  Aml.lastly .  in  tuberculosis,  the  question  of  the  relation 
of  the  cells  to  the  bacilli  is  being  carefully  siudicd.     In 
his  recent  p^per  on  th.  subject,'  Metschnikotf  claims  that 
tl^'   degenTtion  of  the  baciUi,  which  has  long  been 
Inown  to  ..curwithip    the  giant  cells,  results  directly 
from  their  phagorvtic  action,  and  is  not  a  natura    decay 
Balga   en.  on  the  other  hand,  regards  the  relation  of 
the  giant  cells  to  the  bacilh  as  one  of  the  strongest  evi- 
dences agaih^t  the  theory  ..t  phagocytosis^ ^ 

1  Fortschritte  H.  '  Medicin,  1887. 

.Arc  V  fUr  l.v^em-.  Bd.  iv.  I  would  p.ruculudy  recommend 
the  Vu  .ry  of  (■.fner's  to  those  wishing  furth..  details,  and  for  a 
striki"         ie--     •  experiments,  the  pap-r  of  Nuttall's. 

3  \         ,,\v  biv,  Bd.  113- 


ON    PHAGOCYTES. 


21 


With   tlie  relations  of  phagocytes  to  harU.ria,  I  have 
had  so  little  practical  experience  that  I  hesitate  to  express 
any  positive  conviction  on  the  (jiicstion,  but  I  have,  for 
nearly  three  years,  been  working  at  a  problem  identical 
in  all  its  relations,   but  in   which  the  parasitic   bodies 
belong  to  a  higher  class  of  organisms.    I  refer  to  malaria, 
and  to  the  h.imiatozoa  which  occur  in  the  blood  u{  this 
disease.     A  sceptical  attitude  in  these  days  of  hastv  ob- 
servation and  of  still   hastier  conclusions  is  peculiarly 
appropriate.     I  complain  of  no  one  who,  without  ampli 
opportunities  for  |      ,onal  study,  claims  the  right  to  ques- 
tion  the  full   significance  of    Laveran's    important   dis- 
coveries.    Perhaps  better  than  any  cme  else,  I  am  in  a 
poMtion  to  extend   sympathy  to  the    sceptic,    as,    until 
ample  material  came  to  hand  m  1886,  I  was  among  those 
who  looked   upon   tiu'  work  of  Laveran  with  extreme 
incredulity.     The  corroboration  in  almost  every  detail 
which  his  studies  have  received  during  the  past  three 
years  is  in  all  respects  remark  ible.     W-irking  as  he  did, 
alone   in    Algiers,  under   circumstance ,    the    reverse   ot 
favorable,  without  proper  laboratory  equipment,  without 
the  stimulus  to   be  found  in   the  asso(  :  ition  of  men  in 
large  cities,  it  is  not  only  in  the  highest  degree  credita'ile, 
but  most  encouraging,  that  an  army  surgeon,  actively 
engaged  in  the  duties  pertaining  to  his  battalion,  could 
accomplish  so  thorough  a  piece  of  work,  requiring  but 
little  subsecpicnt  conection,  and  receiving  at  all  hands 
ample  confirmation, 

Richard,  in  France;  Marchiafava  and  Celli,  Golgi  and 
his  pujjils,  in  Italy;  Sternberg,  Councilman,  James, 
Shattuck,  and  myself,  in  this  country;  and  \'a:)<;iyke 
Carter,  in  India,  working  far  apart,  have  all  jnacticallv 
confirmed,  with  minor  modifications  and  amplifi'  tio;,- 
Laveran's  observations. 

While  the  invariable  assoiiation  ut  these  parasites  with 
malaria  would  appear  to  be  settled,  their  precise  mor- 
phological relations  are  still  a  matter  of  discussion.      I 


tenderness  on  piilpation. 

I  saw  the  patient  for  the  first  time  on  IVrarch  nth,  and  was  struck  with 
Ills  distressed  appearance.  He  lay  propped  up  in  l)e(l,  liad  slight 
dyspnoea,  dry  tongue,  pul.<e  100,  temperature   100".     lie  complained  of 

'  Uoail  by  title  at  tlui  meeting  of  tln'  Association  of  Americau  Physicians,  Wasliiugton,  1888. 


k*  1 


1li 


23 


OSLKR 


have-  ur,c.d,  from  their  rese.nbhvnc  e  to  other  »--";-;; 
that  tl,.;  shcuUi  be  classed  with  '  -■  «'=";f ''  '  ^^  . 
nnonas  (Metrophanow),  ^vhich  >"/»";'^\=^"/c  ,nsickr^^ 
nads   parasitic  i.,     lie   l,l«od    of  which  ^  ^'''    |  ^  f  ,»; 

::l;u;n^:";.r;S;nr'7n;ht;c;.tecasesth.eexist 
•  t;;::JdWood-corpuscleshyalineandpi.n^ntec^b.^^^^ 
which  undergo  am.i^boid  chan-es,  and  which  -ladual  > 
St  -ovth  corpuscles,  converting  the  h.cmoglob.n  ,n  o 
bhck  niu-nent.  Under  certain  cucumstanccs,  mo.c 
;^j:;^.iunn,  the  paro.ysn.s,  these  j;-^- '--- 
in  size,  and  undergo  segmentat.on,  break.n^^     p  .^ 

umb.^r  of  s  mall  free  spherical  bodies.  In  ^"^^>  '^'  """ ; 
Trs  in  the  blood,  but  more  constantly  ^-^^;^^ 
the  remarkable  flagellate  organisms.  Last  v,  in  more 
chronic  cases  there  are  the  still  more  extraordinary  cies- 
^'r^ms:  Practically,  the  unanimity  which  exiss  in 
the  statements  of  the  observers  above  nanvd  regarding 
l;::^t,dies,  places  the  M-^tio,.  of  th-  e-  -ce  m 
malaria  (and  1  may  say,  based  upon  the  number  ot 
l^gadve   observations,  in    malaria    only)    beyond  any 

reasonable  doubt.  .  ^,       ,■ 

That  thev  truly  constitute  the  actual  germ  of  the   h.- 
ease  is  however,  a  point  upon  which  opinions  may  d. Her 
The  constancy  of  their  presence,  their  absence  in  othe 
individuals  in  malarial  regions,  their  abunckmce  in  the 
'        er  forms  of  disease,  the  destructive  influence    he 
extrt  upon  the  blood-corpuscles,  are  urged  by  Lavaran  in 
evidence  of  their  pathogenic  nature 

However  this  may  be,  the  question  which  here  con 
ce  ns  us  relates  to  the  relation  between  the  phagoc^es 
and  these  bodies.  Surely  one  might  suppose  that  here, 
•f  anywhere,  the  theory  of  phagocytosis  might  receive 
conSrmation  or  rebuttal.  What  but  phagocytes  are  he 
amceboid  forms  of  these  parasites  which  exist  in  the  led 
blood-corpuscles,  gradually  destroying   the  stroma  and 


I       i 


ON    PHAGOCYTES. 


23 


the  hiEmofflobin  until  notliing  but  a  sliull  remains  :■■ 
Here,  indeed,  are  foernen  worthy  of  the  steel,  or,  rather, 
of  the  plasma,  of  the  leucocytes.  What,  then,  are  the 
facts.'  Mow  farr m  we  say  that  in  the  hloodin  malaria, 
the  seat  most  assuredly  of  the  chief  pathological  changes, 
in  acute  cases,  that  there  are  evidences  of  a  struggle  be- 
tween the  phagocytes  and  the  hicmatozoa.  It  has  long 
been  known  that  the  leucocytes  in  this  disease  (i)articu- 
larly  in  chronic  cases)  contain  pigment  granules.  There 
is  no  other  affection  in  which  melaniumia  is  so  constant 
a  feature,  th<nigh  it  is  now  and  then  met  with  in  other 
conditions.  The  leucocytes  obtain  tiie  i)igment  either  in 
the  blood  itself,  or  in  the  liver,  spleen,  or  marrow,  where 
the  red  corpuscles  undergo  their  final  destructive  changes. 
In  an  examination  of  nearly  one  hundred  and  fifty  cases 
of  all  forms  of  malarial  affections,  1  ha\  e  looked  carefully 
at  this  |)oint  with  a  view  of  determining  tiie  exact  mode  in 
which  the  leucocytes  obtain  their  pigment,  and  in  my  ob- 
servations of  the  past  two  years  the  question  of  their  rel.i- 
tion  to  the  various  forms  of  the  hiemato/.oa  has  enga"-ed 
my  spec  lal  attention.  It  may  be  remarked,  in  the  first 
place,  that  there  is  certainly  an  increase  in  the  number  of 
white  blood-rorpusdes,  an  increase  not  associated,  so  far 
as  I  know,  with  any  special  change  in  the  character  of 
these  bodies. 

The  result  of  m\  work  in  tliis  direction  may  be  stated 
in  a  few  words.  In  the  blood,  at  least,  there  is  vcrv 
slight  evidence  of  the  existence  of  phagocytosis.  Here 
and  there,  it  is  true,  we  meet  with  leucocytes  which  have 
included  the  amct'ooid  forms  of  the  parasite,  either  free  or 
still  surrounded  with  the  shell  of  a  red  blood-corjiuscle. 
I  have  but  three  or  four  sketches  in  a  whole  series 
illustrating  this  fact.  Occasionally  a  crescent  may  be 
seen  within  the  white  blood-corpuscle,  more  frei|uently 
the  smaller  free  bodies  which  result  from  the  segmenta- 
tion. I  have  in  my  paper  on  this  subject,  given  a 
sketch  of  a  leuco  vie  Mhich  was  watched  for  an  hour 


} 

T 
f 


!i 


tenderness  on  palpation. 

I  saw  the  patient  for  the  first  time  on  March  .'5th,  and  was  struck  with 
his  distressed  appearance.  He  lay  propped  up  in  bed,  had  slight 
(lyspnooa,  dry  tongue,  pulse  100,  temperature   100^     He  complained  of 


'  Read  by  title  at  the  meeting  of  the  Aaaociation  of  AmiTican  riiysicians,  Wasliiugton, 


1888. 


^^B^l  ^ 

: 

.1 

ii 

j   ■ 

^^^m 

; 

f      1 

1 

.1] 

; 

1 

'    %     ■■     fv'^  -'.  ',  ' 

-I          t 

^^1  i 

i    !■ 

iM 

rl 

I 

1 

i 

Hif^f 

;  -^j^Jj^^^^B^HUi 

^Hi  j  .  J 

m 

^^ 

f 

' 

1 

24 


OSLER, 


and  one-half    and    had   inchided   one    pigment    body, 
and  was  about  to  take  a  second,  behaving  identically 
though  more  deliberately  than  its  great  prototype,  the 
pond  auKcboid.     I  confess  myself  disappointed  in  this 
respect.     It  may   be   urged  that  in   a  blood  drop  after 
withdrawal,  the  conditions   are  not  favorable  tor  study. 
But  the  .ihsence  of  any  great  number  of  leucocytes  con- 
taining   parasites    in    a    comparatively    unaltered   state, 
shows  that  certainly  in  the  circulating  blood  the  leuco- 
cytes do  not  activelv  attack  and  eat  the  parasites.    More 
prob.ablv,  I  think,  'they  pick  up  the  pigment  granule 
after  the  disintegration  of  the  parasite,  or  in  such  regions 
of   the    circulation  as  the  spleen   or  the  bone  marrow 
where  the  conditions  are  more  favorable  to  phagocytic 
action.     Even   on  the  warm  stage  with  the  leucocytes 
displaving  for  hours  amcuboid  movements,  and  in  speci- 
mens which  contained  "foes"   innumerible,  it  was  ex- 
ceptional to  see  evidence  of  active  warfare. 

It  is,  of  course,  more  difficult  to  obtain  evidence  of  the 
relation  of  the  supposed  contestants  in  the  spleen,  liver, 
and  marrow,  the  organs  in  which  regressive  and  pro- 
gressive blood  changes  are  constantly  going  on.     I  have 
not  mvself  practised  puncture  of  the  spleen   in  these 
cases,  as  has  been  done   extensively  by  Councilman. 
Fatal  cases  of  malaria  are  not  now  very  common.     I 
have  only  had  op-)ortunities  of  examining  two,  both  of 
chronic  paludal   cachexia,  the  result   of  prolonged  ex- 
posure in   Panama.     One,  an  ok'   man,  admitted  under 
mv  colleague,  Dr.  Musser,  whose  blood  presented  many 
of'  the    characteristic    forms ;    the    other,    a    profoundly 
amumic   man,  with  a  greatly  enlarged   spleen,  but  in 
whose  blood  very  few  of  the  parasites  were  found.     In 
both  instances  the  liver,  spleen,  and  bone  marrow  showed 
charrcteristic  melanotic  changes.     In  the  spleen  the  pig- 
ment in  various  shades,  from  brown  to  deep  black,  was 
chiefly  in  the  thickened  trabecular  tissues  and  about  the 
vessels.     Teased  portions  showed : 


ON    PHAGOCYTES. 


25 


(1)  Large  numbers  of  leucocytes  containing,.  browi,ish- 
black  pigment  grains.  A  few  of  the  leucocytes  contained 
the  small  anurboid  forms  whicii  had  been  noticed  to  be 
very  abundant  during  life. 

(2)  Larger  cells,  containing  red  blood-corpuscles  in 
all  stages  of  degeneration.  These  cells  were  of  various 
sizes,  and  contained  a  variable  number  of  corpuscles 
from  eight  to  ten,  or  even  more.  .Some  of  the  red  cor- 
puscles contained  amieboid  parasites,  but  bv  far  the 
larger  portion  of  them  presented  the  usual  appearance 
met  with  in  cells  of  this  character  in  the  spleen 

(3)  Large,  irregular,  tlattened  cells,  probablv  derived 
from  the  epithelium  of  the  spleen  capillaries,  which  con- 
tamed  granular  black  pigment,  and  occasionallv  red 
blood-corpuscles. 

(4)  Spindle  or  branch  cells  of  the  reticular  tissue  en- 
closing brownish  or  black  i)igment  grains. 

(5)  Free  pigment. 

Practically  the  condition   was   similar,   thou^di    more 
extensive  in  degree,  to  that  met  with  in  this  organ  and  in 
other  (ebrile  states  associated  with  extensive  blood  de- 
struction.    I  really  could  not  say  that  the  splenic  phago- 
cytes exercised  any  selective  power  in  picking  out  for 
attack   those   corpuscles  which    contained    parasites   or 
crescentic  forms,  which  in  one  of  these  cases  existed  in 
considerable  numbers.     The  bone  marrow  in  both  cases 
presented    micr  )scopic    changes    characteristic    of    the 
lymphoid  tissue,  and  had  a  grayish-brown  color  due  to 
excess  of  pigment.      There  were  in  it  in  large  numbers 
marrow  cells  and  ordinar>-  leucocvtes  containing  irregular 
pigment,  and  occasionally  free  amoeboid  forms  of  the 
parasites.      The   cells    containing  red    blood-corpuscles 
were  very  alnindant,  but  here,  as  in  the  spleen,  it  was 
particularly  noted  that  the  red  corpuscles  not  containing 
the   parasites    were   as    freiiuentlv,    or    even    more   fre^- 
quently,  encl.)sed  in  the  cells.     In  the  liver  the  pigment 
existed  in  three  elements. 


le- 


s- 
'-e 

IS 

y 
)f 

1. 

is 

3S 

d 

g 
ic 
il 

le 

V- 

d 


id 
n 

le 


temiernepH  on  jKiiiKiLiun. 

I  saw  the  patient  for  tlio  first  time  on  March  5tli,  and  was  strut' 
liis  (listrcs.sed    appoaranee.       lie    lay    propjied    up  in   bed,  liad 
<lyspnoca,  dry  tongue,  puli^e  100,  temperature   100'.     He  eomplai 


7 
le 

2 

le 
i\ 
le 

k  with 
slight 
ned  of 


Ilnad  liy  title  iit  tlui  iiiootiiij;  nltlie  .\6,sui'iiition  uf  Anu'riciiii  IMiyticiaiis,  Wiishingtoii,  188fc 


'•!i 


■■? 

1 

t 

1 

\e 

I 

h 

! 

;ii 

( 

25  OSLER,    ON     PHAGOCYTES. 

(,)    In    leucocytes,   which    seemed    numerous   in    the 
h.bu  ar  capillaries,  particularly  '^t.  ^'^^  Periphery 

(.)  In  the  walls  of  the  capillaries,  in  all  probability  in 

^' (^t^:;:^^  str^^'cells,  particularly  of  the  interlobular 
tissue  about  the  portal  canals,  where  in  places  it  was 
f^^ciently  abundant  to  cause  ordinary  diffuse  pi.inenta 
tion,  a  part  of  which  was  due  to  grains  lying  fiee  in  the 
interstices  of  the  tissue.  .i  „  ,.nri«itp<;  are 

Metschnikoff  states  that  m  "-l^/''^'^'^  .l^'^'"  '  Hr^, 
attacked  chiefly  in  the  spleen    nd  the  l'-;;^^^      jarge 
phagocytes  existing  in  these  organs  and  to  a  much  less 
extent  bv  the  leucocytes  in  the  circulating  blood. 

We  see,  then,  in  malaria  very  little  evidence  in  the 
bl^d  Spring 'a  theory  of  P^-^ocytosis ;  c^Uun^y  no 

such  campaigning  on  the  part  "^  ^>- l-'^^^^Sjof^.^ 
be  exuectedfrom  the  presence,  in  such  numbe  s,  ot  to.s 
so  deEuctne  to  the  red  corpuscles.    In  the  spleen,  bone 
marrot  Ld  liver,  the  organs  in  which  the  c-    -dying 
blood-disks  are  normally  cremated,  to  "^^ /  f '  ^    <^^ 
nression    we  have,   as  might  be  expected,   an   actuity 
:       ti;nire  to  th;  increased  amount  of  -tenaUo  b 
•consumed,   but  scarcely   such    '^^ff^^'^^^^'^ 
action  as  would  indicate,  on  the  part  of  the  leucocytes, 

^^in:t;:mSng  theory  that  to  the  action  of  phago 
eves  is  due  the   immunity  against  certain  diseas  so. 
against  a  second    attack.  I   cannot  now  ente  .     In  tlu, 
present  unsettled  state  of  our  knowledge  it  would  be  p.e- 

"To'conciude  :  While  phagocytosis  is  ;-if  esjKead and 
nnportant  phvsiological  process  throughout  the  animal 
k    "lorn  ind  while  it  undoubtedly  plays  a  most  impoi- 
ur'n  in  many  pathological  conditions  the  quest.o 
;,-  an  active  destructive  warfare  waged  by  t^ejoo d      ell 
against  the   microorganisms  of    disease   must   still   be 
considered  an  open  one. 


nifts 


e 


s 
f 

3 
3 


tenderness  on  palpution. 

I  saw  the  patient  for  tlie  first  time  on  March  r)th,  and  was  struck  with 
Ills  distressed  appearance.  lie  hiy  l)r()ppe(l  uj)  in  bed,  had  slight 
tlys])noea,  dry  tongue,  pulse  100,  tenii)eraturc   100'.     lie  comi)lained  of 

'  Rsad  by  title  iit  Uio  ineetint;  ciftln)  Asancliitum  uf  AiiKrirun  Plivsiciaus,  WiiBliiugtuii,  1888. 


A 

■  i's 

{ 

«i 

f<:   ..'1 


I    .!» 


y  \ 


xcv 


Extracted  from  the 
American  Journal  of  the  Medical  Sciences  for  January,  1889. 


PULSATING  PLEUKISY.' 
By  William  Osler,  M.D.. 

PKOFIPSOU  (.F  CLINICAI,  HEIIICINE  IN  THE  VMVEKSITV  OK    I'ENNSYIA'ANIA, 


PuLSATixr,  pleurisy  i.s  sucli  a  nire  condition  that  the  folh 
is  worth  phicin^  upon  record: 

Strain  in  liftinr/ :  pain  in  left  .'<ide  ;  rapid  efimon,  at  first  serous,  neces- 
sdating  two  a»pirations;  pi/o-pueumuthorax ;  ptdmtion  of  side;  free 
drainage;  recowv//.— James  F.,  a-^ed  twentv-tliree  vears.'hihorer  was 
admitted  to  the  University  Hospital  ^Nlarcli  .'],  1888.  Family  history 
good  ;  none  of  his  relatives  have  had  phthisis ;  with  the  exception  o'f 
an  attack  of  rlunnatism  in  188.";,  he  has  enjoyed  uniformly  good  health. 

On  February  the  2;;d,  eight  days  before  admission,  he  sprained  his 
back  by  lifting  a  piece  of  timber  twenty  feet  in  length  and  ten  inches 
in  diameter.  Three  men  were  lifting  it,'  but  one  of  theni  let  go  his  hold 
so  that  the  patient  had  to  exert  his  utmost  strength  to  support  his  end  of 
the  i)iece.  At  the  time  he  did  not  teel  any  discomfort,  but  that  evenintr 
he  became  sore  and  stiH".  He  slept  well,  and  the  next  day,  u  public 
holiday,  he  went  about  with  his  comrades,  but  C(jni|)lained  on  several 
occa.sions  that  he  had  sprained  his  back  with  heavy  lifting.  Duriu"-  the 
evening  the  pain  grew  worse  and  he  passed  a  restless  night.  The  foTlow- 
ing  morning  he  did  not  feel  well  enough  to  get  up  and  the  pain  had 
become  almost  unbearable.  There  was  no  cough  or  shortness  of  breath  ; 
he  docs  not  know  whether  he  hail  any  fever. 

FiOin  the  -iGth  to  the  od,  the  date  "of  his  admission,  he  was  "  up  and 
(lown  ; "  in  bed  part  of  the  time,  and  i)art  of  the  time  by  the  kitchen 
tire.  The  pain  in  the  back  was  his  only  complaint.  He  "is  positive  he 
had  no  cougli,  but  he  was  short  of  breath. 

On  admi.ssion,  the  patient  looked  very  ill ;  face  tlushed,  tongue  dry 
and  coated  ;  respirations  .'JO,  temperature  1004''.  He  was  able  to  lie 
down  in  bed.  The  importance  attached  to  the  lifting  on  February 
2;Jd  nuiy  be  gathered  from  the  fact  that  he  was  admitted  to  the  surgical 
ward  as  a  case  of  injury  to  the  back,  and  subseijuently  transferred.  ''The 
day  after  admisnion  he  had  nuicli  ••ain.  of  a  cutting  nature,  iu  the  left 
side,  in  the  axillary  region  outside  the  nipple.  There  was  also  extreme 
tenderness  on  palpation. 

_  1  taw  the  patient  for  the  lirst  time  on  March  5th,  and  was  struck  with 
liis  distressed  appearance.  He  lay  pro[)ped  up  in  bed,  had  slight 
dyspncra,  dry  tongue,  pulse  100,  tem"perature  100\     He  complained  of 

'  Iteiid  1.1  title  at  the  meeting  ut'tliu  ABsociation  of  Aiiioriciiii  I'liysiciaus,  WiishiiiRton,  1883. 


■  1 


I' 


5  f 


"  I 


2  OSLEK,    PULSATING    PLEURISY. 

al™  t.-.  Ke  .  Ik.  loft  riTlc;  ll.e  inlcrcsuU  s,m™B  ma.sl.nKmAabU^ 
The  o n  y  c»r<li».  mMn,l»  visible  >v„si,.  ll,e,l..r,l  ns  .1  "'"^''l'""-,  i'",  J 
IVenmus  --  •;;;:;;!;;^;:^,,,^^:  ^,^S<;"   ule  bev.na  the  right  „,ar^n 

r'^'Tnf  hph^Vor     he  c  V  pnoea  wa/ relieved,  the  appetite  improved, 

''";^,rTirV,n:iin^n';,f"  !:r!5::-  Co„<li.ion  „f  ,».lent  „a,  i.,.- 

„„  V  d,  H-  84  "o,^i,ali..n  28,  to,a„enUure  1.S-  te™. -"f^fS 
piuviu,  1  .  comphuus  only  ot  chest  ]mui ,  leiifeuie 

2S\t^^u^l!>okB^^^^^^^  au,li«ci.ni.>.keseeu.nt.e 

IZi' <u,a .bird ,,««•« .... i>"'\*lvr::;:^;;;:,tS'': ibo'  re,': 

!;;;:rcsr  ei:^c"i;riSt  itri^p;;:  ,„..  ei,.,.  .„  >i,e 

r,;.!  rib,  ,1.,11  below.  ,l,i.     "■',,;  f.;;5'ttV|:'-E';,,,,,.,„vie,,lar  a,.d 
A  i!u/iiiltMti(ni  •   Iiisuiratioti  is  loi.ti  •uui  uicla^  m  ni*-  .- 

?;r^rrvin'r,,C  ;",„!'  .'.alVle  .L^.  »„  eougbi„..     N„  beU 
r;;i;"T„:i«lrrt.l'Ti.*'u  -  „l«erved  that  the  pe,-ca«ioa 

movable,      ihis  wa*  \ti}  luaiK  ..viUa  became  hyuer-resouant 

.hich  position  t^^  P---""it^.  :^'^\  ^"i^lion  at'outer  angle 
:?Sl  alnlla  --- '  -le  .a^  distinctl^^mpanitic.    To-day. 

?or  theS  ime,  ihl  Ml  s.H.nd  Nvas  obtained  nith  the  co.ns 
V/A    S  nee  the  20th  he  has  had  irre-i.lar  tever  reaching  10-    in  U  c 
2MI,.  >^'"''«  [»«  -;;  ^.1    j,,^,^.|^  ,,^tter.  The  physical  signs  persist; 


OSLER,   PULSATING    PLEUKISY 


11 


sxamination 
detcrniined. 
jmra-stornal 
iiuUlon  onset 
eiilision  had 

:pansinn  was 
tinguinhable. 
>ace.  Tactile 
the  left  side 
rij^lit  niarfj;in 
puncture  the 

full  pleura 
nied  by  Dr. 
ni  removed. 

By  the  Dth 
visible  to  the 
'  the  clavicle, 
turbid  serum 
The  tcm])era- 
ite  improved, 
'  comfortable. 
)e  seen  in  the 

tient  has  im- 
a  seems  quite 
pain ;  left  side 
Ise  seen  in  the 
m.  The  left 
it  the  extreme 
c'lcar  to  the 

clavicular  and 
y  murnuir  has 
■ith  the  breath 
Is  in  the  lower 
tiing.     No  bell 

the  percuirsiou 
ipanitic.  Dul- 
1  was  distinctly 
rijrht  side,  in 
hyper-resonant 
1  at  outer  angle 
initic.  To-day, 
)ins. 

iiig  102'  in  the 
111  signs  persist; 
[ic  lower  border 
,-mpanitic,  from 
rns  on  his  right 
loric  breathing 
■e  the  percussion 


note  IS  dull.  There  was  noticed  to-day  in  the  fourth,  fifth  and  <ixth 
interspu-es  in  the  mid-axillary  line  a  reiiiarkaMc  pulsation  The  whole 
side  recc;ve(J  a  very  positive  shock,  systolic  in  time  and  synchronous  witli 
the  cardia-!  impulse  in  the  third  right  iuters|,u,.e  just  above  tlic  nipple  ; 
the  hand  placed  on  the  left  side  is  distiuctlv  liihd  with  each  iui miUe 
When  he  lies  toward  the  right  side  the  i)ulsa;iMU  in  the  left  axilla  is  a 
httle  more  marked  than  when  he  is  flat  on  his  back. 

mh.  The  (iommon  decubitus  is  .,ii  the  left  side  and  in  this  position 
the  iieart  impulse  is  well  seen  just  above  the  ri-ht  nipple.  The  puis  i- 
tion  in  the  left  mammarv  and  axillarv  reiri,,„.s' is  verv  marked  The 
maxmuim  intensity  is  outside  the  left  iii|)ple.  When  he  turns  on  the 
right  side  the  pulsation  is  most  marked  in  the  fifth  and  sixth  interspaces 
in  the  mid-axillary  line.  Palpation  gives  a  verv  decided  heave  and  a 
distinctshockisfelt.  In  the  erect  posture,  the  pulsation  is  not  so  forcible 
though  still  very  evident.  The  coin  sounds  are  now  unusually  distinct' 
huccussion  is  not  obtainable. 

20th.  'UxG  left  chest  looks  larger  and  fuller  than  the  right  ;  it  is  com- 
pletely immobile.  The  intercostal  spaces  are  obliterated  with  the  excep- 
tion of  the  sixth,  which  is  still  visible.  The  systolic  Impulse  on  the  left 
side  IS  very  marked,  and  can  readily  be  seen  by  the  students  in  the 
distant  seats  of  the  amphitheatre.  Measurement  on  the  right  side  "-ives 
sixteen  and  one-eighth  inches,  expansion  one-half  inch  ;  on  the  leftside 
seventeen  and  one-i|uarter  inches,  practically  no  expansion.  ' 

Pa//;a^"o/^— Tactile  fremitus  is  absent  on  the  left  side.  Heaving 
impulse  in  the  mammary  and  axillary  regions  well  felt  with  the  hand. 
_  PeroAmion.—C\ei\\\  hyper-resonant"  note  to  upper  border  of  the  third 
rib.  From  the  third  to  the  fifth  it  is  distinctly  tympanitic.  Below  this 
in  the  axillarv  region  there  is  dulness.  When  he  turns  on  his  rii,dit  si(ie 
the  pulsation  in  the  mammary  and  axillary  regions  is  more  marked. 
Where  the  jjcrcussion  note  was  dull,  it  is  now  tympanitic. 

Auscn/tatloii.—In  the  left  infra-clavicular  region  the  breath  sounds 
are  loud  and  distinct,  not  amphoric.  In  the  third  and  fourth  inter- 
spaces the  respiratory  murmur  is  scarcely  audible.  In  the  axillary 
regions  there  is  distant  but  distinct  amphoric  l)reathiu^^  very  clearly 
heard  when  a  deej)  breath  is  taken.  No  special  ampluu'ic  echo  ai)out 
the  voice,  the  vibrations  of  which  are  not  communicated  to  the  ear;  pos- 
teriorly there  is  distant  amphoric  breathing. 

-9./.X/.  The  irregular  tln-er  has  persisted  and  the  presence  of  pus  was 
demonstrated  with  a  liypodcrmic  needle.'  It  was  decided  to  open  the 
pleura,  which  was  done  by  Dr.  Ashliurst  :  fully  three  pints  of  pus 
escaped.  A  large  drainage  tube  was  inserted  in  the  eiiihth  interspace 
below  the  angle  of  the  scapula.  After  the  operation,  the  heart  did  not 
return  to  it.*  normal  position,  though  it  boat  to  the  left  of  the  sternum. 
Patient  sto».d  the  operati(Ui  very  well,  the  evening  temperature  was  only 

oO.Z    , 

April  3.  Pulse  92.  respiration  24,  temperature  98^.  Ins])ectlon  showed 
a  remarkable  change  on  the  it-ii  side  of  ihe  chest;  it  already  looks 
smaller  tlian  the  right,  and  then-  is  fiuttenmg  in  the  seomd,  third,  fourth, 
and  fifth  intercostal  spaces  ;  there  is  very  marked  pulmonary  resonance 
to  fourth  rib.     Tympanitic  in  the  fifth,  sixth,  and  seventh  interspaces. 

With  the  exception  of  the  fifth,  when  the  temperature  rose  in  the 
evening  to  102 ^  the  patient's  condition  was  most  satisfactory.     He  slept 


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4  OSLER,    PULSATING    PLEUKISY. 

well  upp(.tite  fio.Kl,  ten.peruture  did  not  rise  above  99°;  there  was  free 

'^t^C^irta^^d  to-dav:  ri.ht  .ido,  ijfWn  an.l  a  h.lf  inch^; 
left  ti  oen  and  one-eiKhth.  Di.cl.arge  very  1  ^d.t.  Fro.n  t  u.  tune  the 
patient  in.provcd  verf  rapidly  ;  ton,peralnro  has  n.,t  m.n  above  100 
^  May9.  The  diseharjre  i.  now  slij^ht.  ,  A  sn.aller  dnunage  tube  ^,. 
introduced  ;  the  .iisduu-ge  ^n-adually  .lin.in.shed  and  he  unproved  rapulK 
n  strength  and  wei^lU.     ICarlv  in  June  the  tube  was  removed. 

June  10    The  note  is  that  the  .inus  has  entirely  healed.     He  left  the 
hosiSal  on  the  15th,  weighiuf,^  140  pounds,  a  gam  ot  twenty-two  pounds 

'^'Th^milm'mof  his  chest  on  discharge  was  as  fbllows:  There  was 
marked  flenin;.  of  the  left  side,  particularly  in  the  axillary  and  mam- 
ma ve"ions.  The  eireumferenee  was:  ri.d.t,  fifteen  and  three-ciuarters; 
eft  fiftm.  and  one-.p-artor  inches.  The  percussion  note  was_  dear  to 
he  fifth  Hb  and  the  Ipine  of  the  scapula  behind,  bdow  these  points  there 
'vLs  dulml  Loud 'breath  sounds  in  the  davu.ular  and  mammary 
regions,  feeble  and  distant  in  lower  axillary,  and  at  base. 

I  bdieve  that  this  was  an  instance  of  pneumothorax  from  the  outset, 
one  of  those  interesting  cases  to  which  Dr.  ^^amud  West'  and  Dr.  de 
Havilland  HalF  have  called  attention,  in  which  the  condition  has  ol- 
lowed  strain  in  a  person  previously  healthy.  It  is  very  improbable  that 
on  the  eighth  day  of  an  acute  pleurisy  there  would  be  a  serous  exuda- 
tion of  such  extent  as  to  reach  the  clavicle  and  encroach  on  the  pleura 
of  the  other  side.  On  the  other  hand,  the  percussion  note  as  is  wdi 
known,  may  be  dull  in  pneumothorax  when  the  tension  of  the  thoracic 
wall  is  very  great,  and  I  think  that  in  this  way  the  mistake  arose.  I  he 
mode  of  onset  in  a  healthv  man,  the  course  of  the  disease,  and  the  rapid 
and  complete  recovery  favor  the  view  that  the  strain  had  i.uluced  a 
pneumothorax  which  excited  the  pleurisy. 

The  chief  interest  of  the  case  lies,  however,  in  the  curious  phenomenon 
which  developed  in  the  fifth  week  after  the  attack. 

Instances  of  tumors  of  the  thoracic  wall,  which  pulsated  synchronously 
with  the  heart,  are  mentioned  by  several  of  the  older  wnters-BaiUoii 
(1640)  Le  Kov  (177(5),  and  Pdletan  (IHlO.-but  the  first  cnses  oi  pu  - 
sating  empvema,  recognized  as  such,  were  reported  by  the  late  Dr.  R. 
L  Macdonnell,^  Professor  of  Clinical  Me.lidne  in  McG.U  University 
Montreal,  who,  at  the  time,  was  dinical  assistant  to  Drs.  Graves  and 
Stokes,  at  the  Meath  Hospital,  Dublin. 

In  the  first  of  these  cases  a  large  tumor  appeared  in  the  cardiac  region, 
whidi,  after  pulsating  for  some  time,  became  red.  tense,  an.l  shining, 
and  then  burst,  giving  exit  to  a  large  quantity  of  pus. 

In  the  second  case  two  tumors  appeared  in  the  lower  part  ot  the  lett 


1  Clin.  Sue.  Tmnsnctidiifl,  vol.  xvii. 

»  Uublia  Jouru.  Med.  Science,  March,  1814. 


2  n)lil.,  vol    XX. 


3LER,    PULSATIxa    PLEURISY. 


art  of  the  left 


Whon    opened   purulent 


aide,  presenting  fhiotuntiun  iind   pulsation, 
matter  escaped  in  lari^e  (piantities. 

In  the  third  case  two  hu'fre  tumors  appeare.l  in  the  lower  portion  of 
the  left  side  of  the  ehest,  presenting  fluetuati,.M  and  pulsation  Thev 
were  opened  and  discharged  a  large  quantity  of  pus.  Death  followed 
in  all  these  cases. 

Dr.  Macdonnell  remarked  that  this  (•on(liti,.n  was  new  in  the  history 
ot  empyema. 

Several  careful  studies  of  pulsating  pleurisy  have  recentlv  heen  made. 
One  by  Comhy/  who  collected  27  cases;  and  a  second  by  Kepler'^  who 
has  collected  .S8  cases,  only  2  of  which   are   reported'  by   American 
authors-Drs.  Flint'  and   Dillingham,*  from  the  wards  of  Dr    J    H 
Ripley  at  St.  Francis  Hospital,  New  York. 

I  am  able  to  ad<l  the  reports  of  a  few  additional  cases  from  this  side 
of  the  Atlantic,  but  from  inquiries  which  I  have  made  from  the  hospital 
physicians  of  this  country  the  condition  appears  to  lie  extremely  rare. 
Dr.  George  Ross,  Professor  of  Clinical  Medicine  in  McGill  University 
Montreal,  has  given  an  account  of  an  e.vtremely  interesting  case,^  which 
closely  simulated  aneurism: 

A  man  aged  thirty-seven  years,  was  admitted  to  the  General  HosDital 
sudenng  from  pan,  in  the  side,  cough,  an.l  fever,  wlmli  lasted  ahou?five 
days,  mul  which  1..  lowed  a  severe  wetting.  There  was  deficient  expansion  on 
Wi,  fi  t "  T"'  'h'"'''  *"  "•"  '">K'leof  theHcapuluand  diminishell  fremitus 
i,n  i  >H  Ti"-''  t''«  ^■•^P-"':^;^'e  "."•^■^■nient  of  the  left  side  became  more 
impu.ed.  The  second  and  third  intercostal  spaces  in  front  became  promi- 
nent, presenting  perceptible  pulsation  synchronous  with  systole  of  the  heart 
About  five  days  after  the  onset  of  the  illness  he  had  a  severe  fit  of  cu-diin"" 

less.  Ihe  cough  continued  tor  a  few  days,  witli  expeitoration  of  ims  The 
percussion  note  on  the  left  side  became  dearer  and  the  pulsating  "tumor 
entirely  disappeare.!.  The  temperature  fell  to  norma!  and  the  man's  stren-th 
returned,    ien  weeks  from  the  onset  the  man  left  th.'  hospital  strong  and  well. 

Dr.  F.  P.  Henry,  of  Philadelphia,'-'  reports  a  case  from  the  Episcopal 
Hospital : 

Woman,  aged  thirty  years,  admitted  in  the  spring  of  1880.  On  the  left  side 
ot  the  thorax  there  were  three  strongly  \mU:ituvX  tumors-one  about  the  size 
ot  half  a  large  orange,  m  the  left  mamm.u-y  region,  direetlv  over  the  eentral 
portion  o  the  heart;  a  second,  much  smaller  and  acuminated-;.,,  with 
apex  much  smaller  than  the  base-was  situated  on  the  left  antero-inferior 
portion  ol  the  thorax  ;  and  ii  third,  the  largest  of  the  three,  on  the  left  postero- 
inferior  portion,  its  long  diameter,  al)out  four  inches,  eorrespondin-  with  that 
it  tlie  vertebral  column.  All  these  tumors  possessed  a  strou"  expansile  svs- 
0 he  pulsation.  The  day  after  admission  pus  was  withdrawn  hvpoderini- 
ally  itom  the  smaller  tumor.    The  ,  i-uor  over  the  heart  contained  air,  which 

I  Archives  Genf  rales,  1883. 

*  Doiitsches  Arcliiv  I'iir  kliti.  Modicin,  1. 1    xl.  1887. 

«  Cliiiicil  Uepoit  on  Cliruiiic  IMouritis,  p.  47  ;  aud  Ou  the  Roepiratory  Orgaus,  p.  .181   18.56 
••  Now  Ydi-k  ModicKl  Ucconl,  1884.  ' 

'  Canadii  iled.  and  Snr}:.  Journ.,  May,  1885. 

•  Proceedluga  of  tlwi  I'hila.  Co.  Mod.  Sui-i.ity,  vol.  iii.  p.  8.i. 


O 

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OSLER,    I'ULSATING    PLEURISY. 


was  vcrv  evident  on  iniinipiil  ition.  AH|.iriiti..n  was  p.T  ,rmcHl,  and.  some 
time  aftor.  a  .IraiiiMuv  tub-  wa.  inserted  l.y  Dr.  AsI.Ii.hni.  The  woman  wan 
removed  l)y  lier  IViemU,  but  was  alive  a  year  ultcr  tlie  ..[.eration. 

Dr.  Jancwuy,  of  Now  York,  wrltos  that  he  liaa  met  witli  ouo  case  of 
empyeniii  of  tlie  iolt  side,  in  which  the  tiunor  was  situated  in  the  left 
second  interspaco,  which  pulsate<l  when  tlie  patient  stood  erect,  but  when 
the  patient  was  Ivinj;  down  air  lilUnl  tiie  sac. 

These  cases,  witii  the  thirtv-ci^'ht  collected  from  literature  by  Comby 
and  Kepler,  make  a  total  of  forty-two  cases.  The  condition  is  almost 
invariably  met  with  on  the  left  side.  In  only  three  instances,  those  of 
Kepler,  Ileyfelder,"  and  Geigel,'  was  the  empyenui  in  the  right  side. 
Kepler  thinks  there  mav  have  been  a  doubt  in  Meyfelder's  case,  but  the 
report  seems  perfectly  clear.  The  tumor  appeared  between  the  second 
and  third  ribs  on  the  right  side,  and  pulsated  distinctly.  It  may  possibly 
have  been  a  mediastinal  abscess,  as  it  was  close  to  the  pleural  margin. 
Only  eiirht  ounces  of  pus  ilowed  out  when  punctured. 

In  iiu-  -ise  of  Geigel,  a  man,  ;et.  fifty-seven,  had  in  the  right  mani- 
marv  v.  ^•ion  a  prominent  projection  which  pulsated  synchronously  with 
the  U.-:  i:t,  The  case  terminated  fatally.  Between  si.K  and  seven  pounds 
of  pii'^  vvTe  found  in  the  pleura. 

Empyema  existed  in  all  the  cases,  with  the  exception  of  one  reported 
by  Kepler,  from  Eichhorst's  clinic,  in  which  the  fluid  was  serous.     It 
occurred  in  a  boy  ait.  fourteen,  who,  fourteen  days  before  his  admission, 
had  been  seized  with  a  severe  pain  on  the  right  side,  and  shortly  after- 
ward great  tenderness  at  the  seventh  rib.     There  was  dulness  at  the 
right  base,  which  rapidly  increased  until  it  reached  the  angle  of  the 
scapula,  and  within  a  few  days  there  were  signs  of  effusion  in  the  right 
thorax.     On  first  examination  the  right  side  was  enlarged,  intercostal 
spaces  prominent.     There  was  active  pulsation  over  tht  antero-lateral 
region  of  the  right  side  of  the  chest  reaching  as  high  as  the  third  rib, 
and  synchronous  with  the  movements  of  the  heart.     The  apex-beat  of 
the  heart  was  1.5  cm.  above  the  nipple  in  the  left  mammary  lino.     On 
account  of  suffocative  svin[)toius  aspiration  was  performed  and  800  c.  cm. 
of  pure  serous  fluid  removed.     At  a  second  puncture  200  c.  cm.  more 
were  removed.     Pulsation  ceased  after  the  withdrawal  of  the  fluid.     In 
fourteen  davs  the  fluid  reaccuinulated.    An  exploratory  puncture  showed 
it  to  be  pus,  and  the  operation  fur  empyema  was  made.     The  seventh 
rib  was  resected  and  300  c.  cm.  of  pus  removed. 

In  only  two  instances  of  Kepler's  series  was  pyopneumothorax  present. 
Ono  reported  by  Fer^ol,'^  a  man  ret.  twenty-two,  had,  in  July,  1882,  left- 
sided  serou.s  ert"usion,  which  was  tapped,  and  he  recovered.  On  October 
27th  there  was  again  a  large  left  side  effusion  with  air.  The  beat 
was  at  the  right  nipple,  and  about  the  end  of  November  pulsation  t)f 


1  Abstract  by  Kepler,  1.  c. 


2  Quoted  by  Kepler. 


OSLER,    PULSATING    I'LKURISY.  7 

the  wholo  Mi  si.lo  was  noticed,  .ynrhronous  with  the  heart  It  was 
mo,st  .narked  behind  and  in  the  axilla.  The  aspirati.n  of  2\  litres  of 
pns  alK,h«he.l  the  p.d.sation.     In  Dilli„,duun'.  ea.se  the  n.an  had"  pnenn.o- 

To  these  ,.a«es  mnst  he  added  the  one  whieh  I  here  report,  and  the 
cases  of  Henry  and  Janeway,  in  borl  which  there  was  evi.lently  air 
m  the  pleura.  ^ 

_  Two  .roups  of  cases  may  be  recogni/.ed:  1.  (he  intra-pleural  pulsat- 
in;j  pleurisy  ;  2,  the  pulsating  empynni  ..eee.-.itatis.  in  which  there  is  an 
externa  pulsatn..  tun.or.  The  latter  condition,  the  ,no..t  connnon 
occurred  in  twenty-five  of  the  forty-two  cases,  pn.bublv  .U,,,  ;„  ,,  j.^,,,,; 
proi.ortion,  as  there  are  several  reports  with  very  scantC-  details  The  ex- 
ternal tmnor  is  usually  single,  hut  in  live  cases  there  were  two  tumors,  and 
m  one,  Dr  Henry  s  case,  three.  The  perforation  of  the  pleura  usuallv 
occurs  ,n  the  anterior  aspect  of  the  chest,  from  the  second  to  the  sixth 
rib,  sometnnes  close  to  the  sternum.  In  three  cases  the  tumor  appeared 
posteriorly-at  the  spine,  at  the  angle  of  the  scapula,  an.l  in  the  lumbar 
region  In  the  intra-pleural  cases  the  pu  Isation  is  usuallv  in  the  antero- 
lateral region  of  the  aHected  side,an<l  may  be  eviilent  on  palpation  only 
or,  as  ,n  the  case  here  reported,  it  may  be  visible  even  at  a  distance        ' 

Pulsating  pleurisy  usunlly  occurs  in  cases  in  which  the  flui.l  has 
existed  for  some  time,  but  that  it  may  occur  in  acute  cases,  even  with 
a  serous  exudation,  is  illustrated  by  Kepler's  patient.  In  Ku.ss's  case 
and  in  mine  the  condition  was  also  acute. 

Various  explanations  of  the  phenomenon  have  been  offered  Dr 
Broadbcnt'  suggests  that  it  occurs  when  adhesions  exist  between  the 
layers  of  the  pericardium  and  between  the  pericardium  and  the  chest 
wall.  But  that  this  cannot  hold  g..od  in  all  cases  is  shown  bv  reports 
of  post-mortems  in  which  such  adhesions  were  iu,t  present.'  Traube 
regarded  destruction  of  the  costal  pleura,  and  marke.l  paresis  of  the 
intercostal  muscles  as  the  conditions  which  rendered  pleurisv  po.«sible 
In  the  case  which  I  have  reported,  there  was  persistent  tenderness  of  the 
thoracic  walls,  suggestive,  to  say  the  least,  of  involvement  in  an  unusual 
degree  of  the  parietal  structures,  but  there  was  no  cedema  or  special 
protuberance  of  the  spaces,  and  the  condition  came  on  too  early  to  have 
been  due  to  destructive  changes  in  the  pleura.  It  was  probably  due  to 
extreme  distention  of  the  side.  Bonveret,  in  his  recent  monogra])h  on 
empyema,'  holds  that  the  pulsation  is  met  with  whenever  the  resistance  of 
the  thoracic  wall  is  greatly  reduced,  as  in  the  way  Traube  suggests,  or 
when  the  resistance  on  the  part  of  the  diaphragm  is  heightened,  as  by  the 
deposition  of  a  thick  layer  of  fibrin.  The  fact  that  the  abstraction'of  a 
very  small  quantity  of  fluid  will  at  once  abolish  the  pulsation,  indicates 

'  Lancet,  1881. 

-  Traite  do  I'oiniijenie,  pur  L.  Boiiveiot,  Paris,  1S88. 


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Sciences 
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2S  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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b  OSLER,    PULSATING    PLEURISY. 

that  a  certain  degree  of  pressure  is  a  necessary  condition.  Comby  thinks 
that  ..he  pulsation  only  occurs  when  the  lung  is  compressed  and  adhe- 
rent to  the  pericardium,  so  tliat  the  heart  nKJvements  are  communicated 
through  it  to  the  ])leural  f'l  ;i(l,  and  «o  to  the  che  ♦^  wall.  l'\'reol  makes 
a  somewhat  similar  suggestion,  holding  that  in  every  instance  the  condi- 
tion IS  one  of  pneumothorax,  in  which  air  forms  an  elastic  cushion 
between  the  pericardium  and  the  fluid  through  which  the  pulsations 
of  the  heart  are  directly  transmitted  to  the  cho.-Jt  wall. 

The  cashes  have  been  mistaken  for  aneurism,  and  the  situatio.i  iu 
which  the  pulsating  empyema  necessitatis  usually  develops  renders  the 
error  very  jiardonable.  The  doubt  can  readily  be  solved  with  a  tine 
hypoileiniic  needle. 

The  prognosis  in  pulsating  pleurisy  is  not  very  favorable.  Of  the 
thirty-eight  cases  in  Kepler's  series,  seventeen  died.  But  we  must 
remember  that  most  of  these  cases  occurred  before  the  days  of  safe  and 
frequent  operations  upon  tiie  ch"st  wall. 

Complete  evacuation  of  the  fluid  with  free  and  permanent  drainage 
meets  the  indications  for  treatment. 


<^  1  <  c^  ic  -'/r.' 


-t  -j», 


'/ 


*»  ^.* 


CV/- 


f.*-:. 


_>!<=•  vT 


'/*"  A  .;^  -^  /  .^ 


\lui»ii:t  fro'H  -'//vr;,- 


■"'^''"'■'■"/■///.■.I/,v//,„/„w,y,,, 


Miiryli 


Vliiin 


/'■ 


/-v    I 


'I'y.iKi/  luuiilly  Kj 


/Vnnual  Address. 


'I'HE    i.K'EXSE    To    I>RACTISE. 

HV    Wll.MAM    Osi.lK.     M       J) 


ori\ 


anent  drainage 


f'"-  ".akin,,  ,„e  ■■r.ici  f   Vvlu  ;."'  .T"  "",--■■■  •■•">■  ;'i-'"K- 

'">■  ■■-'  pn.rcsHi,,,,..,,  ,„,    0  ,,l    i,      .    ""    '";■  '■'^■"  ""* ■ 

•"•■'t  i.  is  a  H„l,ioo.  .I,.„u.l,t  '     ■        ;""  ""■'■  ■•'"'"" 

'lis>"ssi"n.  a„<l  m>„n    v1,    .,    r         "','"1""   "i-niisinK    licalcl 
I.C'W,      S.ill  "     1,0        ,.  ,  """"!■■"■■■■■■'">■  "Pl-itc.  view.  arc. 

.iu'sc  »I,„  h„  ;  ,,■'■""     ,"""•■■"•«'">■   -'-'"'"'■  "n.! 
.nicer,.-,,-,,  l„„os  ,^^1.  , ,,   ,'  ",""''  '•'"""''  ^''^'■^  '""  "'  "" 

i..R  the  fooii,.,s  ,f  ,,r,,e ,  ho,'  ;;T;,r       -^  '■^^■-■'•■""- 

l".IJc-,oJ.  tl,c,-of„ro,  t„  s,,oak       '   I,  '.•■•">,'l'^-"."roo,„ 

.■"l<lrcs«  „,o„  wl,„  I,.,  ,      i         ,  •  ""'"  '""  "^'l'  "'■"  I 

»'."  fcn.nv,ffl,i:f  ;:/;•;;'' """  "■""«'■'  -  .ik.,„-,.,„o„,. 

In  this  c„„n,,.  i>l>|.r"-iMo  its  in,|,oit.-„,oo, 

ivsls  with  the  State,  n..,  t  k.,,'"      f'.  ^'^\P'^'^^t=^^  "<  .ucdicinc 


ri.ijlit 


and 


f< lines  witliin  tliat 


'elic'\c  It  is  ack 


priitc'ction   to   tlie   lif 


;viK'raI 


now  ledn-cd  that  th 


IS 


tins 


f  and  hnil 


)s  o| 


power  IS  \eiy   \ar 


lonsly  exereised  in  di 


police  power  wliieh    extend,'- 
li^-  citix.ens.      At  ])resent. 


'erent  States.      1 


'i 


!-■ 


n 


WII.I.IA.M      nsLKR,     .M.     1). 


many,  no  rc"ni 


lati 


(»ns   w 


hat 


cwv  exist. 


A 


nv 


mc   who  wishes, 


irrL'spccti\L'    <»!    c|ualifio(ilions,    vim    vnicUsv.      In    a 


majority 


however,  tliere  are  restiictions  whieli  (knuiiul  evidence  on  the 
l)art  of  tile  ])raetitioner  tliat  he  has  stiuhecl.  for  a  lons^er  or  a 
shorter  period,  at  an  incorporated  school.  Practically,  the  rule 
l^revails  that  witli  a  diploma  from  a  charlered  seliool  lie  can 
bes^in  at  once,  without  an_\-  hindrance  other  than  that  relatin;^' 
to  re.^istration.     The   educational   duties  of   the   State  do  not 


here     e.xtenci 


hcvonc 


th 


e    svsten-.    of    common 


and 


schools,  thou'di,  in  a  few    hisjher 


unu  ersi 


ty 


wo 


rk  is  also 


norma 
under 


taken.  Special  edtication  does  not  receive  support  from  the 
public  re\enn.^s.  Schools  of  law.  medicine,  ens^ineerinii-.  the 
olo.uy.  all  the  special  branches  of  study,  are  private  enterprises, 
chartered  by  ihe  State  and  maintained  by  fees  from  pujjils.  or 
by  tlie  munificence  of  private  friends.  Certain  jiriv  ilej^es  arc 
.^ranted  to  these  Institutions  by  the  State,  the  most  important 
of  which,  in  the  medical  school,  is  the  reeo^nition  of  the 
di])loma    as  a   qualification    for   practise.     So    unsatisfactorv. 


however,    has   this  system   proved,  that  there  i 


s  ( 


)n  th 


e  part 


the  ])ublic,  and  of  the  profession,  a  j^-rowins.;-  sen.sc  of  the  neces- 
sity for  radical  chanj^^es,    as  shown  by  the  number  of  ■,  in 
which  bills  have  either  been  already  passed,  or  have  ..i  .u  he 
fore  the  lej>islatnres  dealinj.^-  with  the  ])roblem. 

It  is  universally  conceded  that  the  basis  of  let^islation  is  the 
necessity  of  proteetini;-  the  people  aj^ainst  the  depredations  ol 
i,L;norant    ^^raduates    and    of  quacks.      The  aim  is  to  provide  a 


m 


inimum  standard  of  qualification  to  be  exa(.ted  of  all  per 


sons 


who  desire  to  follow  the  calling-  of  physician  and  sun 


fcon. 


Whilst  we  find  Lc.iifislatures  everywhere  will 


ino-  to  support  en 


actments  necessary  for  the  safety  of  the  public,  they  will  iioi 
(and  it  is  rij^ht  that  they  should  not)  sui)port  clasK  Ici^-islation: 
and  herein  lies  one  of  the  chief  difiiculties. 


rf 


v\e 


1. 


th 


around  upon  tnose  en.ga.^cd  m  the  practice 


medicine, -we  find  that  an  overwhelmins^-  proportion  bclonjis  li 


the  regular. 


or 


so-called,  old  school.      A  second  small  division 


professes  to    follow  the  preeci)ts  of  Hahnemann:  while  a  ihin 


.still  smaller,   neither  one  th 


in"' 


n(^r  the  other,  but   a  liltl 


both,  professes  a  judicious  eclecticism.  These  three  bodic; 
have  schools,  medical  journals,  and  in  each  State  a  more  oi 
less    complete    orj^ani/.ation. 


In    the    eves  of  the   la 


W     (  W  llli' 


•nVlitly  disreoards  medical   theories)    ,1M,,,  ,        ,  ^ 

^'-'^''i'v   division   uf  theI„Hiv   medic-    \  ,""'■     '' '"^  ''"- 

H.^hcst   mo„.ent.     The  ..'utcouK-    >      t        h''/'         7^ '"'  ''^^• 
^'•^-  hostile  camps  atid  bitter  war  """  ''^'"  ''^^•'•^' 

"-  "-essitv  of  a      dl       c   ""  "  •""'  '  ^''"'-  ^■""-"-  '" 

.-at  branches  of  „. J^^/^  ''^;-  ^•'"•'•'-'-n  <>f  study  in  the 

'^i->io,3^  end.ryo,o,, ;;;:;.,  r::-;;j;:^'';''r-''^""^^'->-^ 

^•oloM-y,    and    medical    jurisprtKlence  ^      "^'■'^^'^'"•^•^-   .^y"-'^'- 

diffcrences  onlv  bcon  e  ,  "    ""    "  ^''''''■"     The 

'n-rapeutics,  a  s^:     „^^'i:;f  ^^'^^"  ^  ^^'^  the  subject  of 

tl-    so-called    scho^t  :  i;:r"T.r"''-      ''^^^^^'-'^ 

"P'"-"  -ist.     So  strong   how^;     '"  ';  "i"^'    ^''*^— ^    <,f 
-'thical  one),  that  the  div'e  .,'     e     Z"  '  '^'^'""■^-  "''^'•.^^■'v  an 

separates  absolutelv  th-hJfe-e^-h  ""''•''"  ^'"■^  "'"'  '^'•^"-''^ 
-eh  other:  and  I  do  not  s^;  f  V'^:"'''""''^  ^'•"•" 
^^"ticp:ated   do^^as  arc   nn  1  .^'^" '^'-'"^l  ""t  be  so.  while 

and  a  free  science.  '  "'   '"  "PI>-'-n   to  a  rational 

^-  ^'-  protection  oM        ^    H^t- T"^' ■'' ^  ^^'^ '^^-'ation 
.uether.    not   sin-dv       I  kno      r;  "'"  '""^  ^"  ^'^■'^-  ^■•>'-  ^^  to 

--y-at  the  i;;t  ern  ss         t1^  ^"^  '^  ^:'"  ^^"'^  — -1  - 
t'on  which  has  to  be  n  c       ij^    f"'"''  ""'^  '"^  '^  '^  ^^  '1'- 
of  the  nine  or  ten    i    W  s  w/-?     "l""'''^''     ^^''^-'  ^^  ^'^'^'^ 
surely,  in  the  inte^-^  t  o^^  J  'll /;  1^^  '^^^-'  '"  — -  -  n,ay 

-H^^eronthe.p,est,on::;^£;:;-;:;;:r'"-''-^'^'--^^^'^^^^^^ 

In  e<mncction  with  the  license  to  ,)ractisc   tl,  .,• 
to  me,   three  courses  open-      ,      \  tl'eieare.  ,t  seems 

present,    widelv   nrevaiHn         i     ,      ''""tnmance  in  the  plan  at 

-  t.e  fitness  .^tr::;:;;;^:-;-^^^ 

(ar  exercised    that   the   dinl  supervision  is  onlv  so 

'•■ '.."">■  i""-p',a'  ':;;;::,,;''\^''''^/'"''  ■-«■■*-"■ " 

tiK'  State  or  bv  I).  rti,.<    .      1  ,  "■         '■'  »l>IJ"n.tmoiit  bv 

wltiC,  »„„„.   i    ,    ;      "^,  "'  '^;;""'«'  "f  "  '>--<I  "f  cx„,„i,u.,,, 

,,  ,  1  n--'lil  I  tl\  t      Ot      tlIT>!oill;]<      ,,..„.„.•...         ,.  ... 


Ill 


or  the  license. 

each   State  int 
tives  to  a  central  pa 
i-elatin.u-  lo  medical 


tiipMonias.  e.xami 


le  nrt^anizati( 


n   of  the  enti 


ne  all  candidate.' 


o  an   electorate,  which  shall  send 


'■lianicnt. 


na\  iiii.-  fill 


re  profession 
veprcsenta- 


ediicatioii.  cxaii 


eontrolofall(piest 


ions 


j  ■■ 


,  4 


H:! 


I 


I 


i 


inalion  and  rc^.-jst 


ration. 


wiiJ.iwi    ()si,i;u,    M.    I). 


These  \arious  places  are  at  ])resent  in  operation  in  different 
ixirtfi  of  the  (.'ontinent:  let  us  see  how  tliev  woi'k. 

And  Hrst  of  the  eollei^es,  whieh  ha\e  praetieallv  had  a 
monopoly  for  years,  as  tjie  diploma  has  carried  with  it  the 
jiriv  ilei;e  of  re,L;'isiration. 

To  all  intents  and  ])urposes  the  medieal  schools  of  the  conn 
try  are  ])rivate  origan i/.ations,  manas^cd  in  the  interest  of  the 
]irofessors,  who,  with  seareclv  an  exee])t]on.  have  direct 
l)eciiniary  interests  in  the  size  of  the  classes.  The  .greater 
the  number  of  students  and  t^raduates,  the  lart^er  the  fees,  and 
the  hit^her  the  income  of  the  teachers.  The  runnins^- exi)enses 
and  the  interest  on  the  moneys  expended  for  the  teachint^-plant 
are  the  first  call,  after  which  the  balance  is  divided.  'I'h<.\se 
chartered  corporations  are  wholly  irresponsible,  without  super- 
vision by  the  State,  the  profession  or  the  public.  It  would  not 
be  difficult,  without  fear  of  just  rebuke,  to  brinj^'  a  railinj^^  ac- 
cusation aj^ainst  theni  .  persistently  actin.n'  in  their  own,  and 
not  in  the  interests  of  the  public.  But  the  time  has  passed  for 
this.  Yet,  it  is  surprisini^'  to  think  that  so  many  men,  distin- 
j^uished  in  every  wav  in  their  profession,  cultured  and  liberal, 
stdl  elins;"  to,  and  even  advocate,  the  advanta,n'es  of  an  irrespon 
sibility,  which  has  made  the  American  sxsicni  of  medieal  educa- 
tion a  by-word  amons^st  the  nations. 

Let  me  not  be  misunderstood.  These  very  men  are,  in  many 
instances,  th.ose  whom  we  delij^ht  to  honor,  with  names  which 
will  last  as  lonj.;-  as  American  medicine.  Vet,  to  an  unbiased 
mind,  there  can  be  no  hesitation  in  attirminj^'  that  the  system 
which  has  been  permitted  to  develop  in  our  midst  has  done, 
nay,  is  doinj^-,  irreparable  wroni;-.  But,  it  may  be  uri;ed,  on 
the  part  of  the  schools,  that  they  are  ,vhat  the  profession  wishes. 
The  stream  does  not  rise  hij^her  than. its  source.  I  do  not 
think  that  this  holds  .n'ood  at  present.  It  docs  not  rc<|uire  a 
\ery  wide  professional  ac([uaintancc  to  .i>ather,  that  there  is 
now  de\elo])inj4-,  throuj^hout  the  leni>th  and  breadth  of  the  land, 
an  earnest  desire  to  support  a  hij^her  medical  education,  ami 
this  is  borne  out  1^-  the  success  wl:ich  ,ias  attended  the  tenta 
tive  efforts  in  th  direction  of  the  larj^er  schools,  which  ha\L 
made  a  three  years'  college  course  ccmipulsory. 

Mere,   let  me  remind  those  doctors  whf)  talk  loudlv  of  medi 
eal   reform,  of  the  selfishness  of  schoolmen,  of  the  diffieultv  in 


)n  in  (lifVercnt 


)iullv  of  mcdi 


"f  »>"<ly.   .lK.,v  „„„„,,,■:""   ","'"•  f""  5-™.-  .Ik.  c,„„.s. 
xNVlncs,  <l,„„,,  .„  ndii   ,.     ,  ,"         "'™  "-.-'■""l^.  »itl,„„tel,c. 

"-;  •>"."'-■  of  s.,«>e„.:r :  ,,  7  ;';,  7"; "-  -i-.i,..,  i„ 

-'"r  "•  nn,  .K.SC.  ,„,■«,.  c,,.,,,  :,,,:,  '''7;"''''' ''^' '''''■•- 
"I'Hl.mc.nt.  .Maiiifcsllv.  it  „„„l,i  ,',."'"''  I"'^'*"'  f"" 
-'-  "f  -n,,si.fc  „i„,  ;,     „  ;"'-;hl-.«i.lH.,„,l,.,,„a,. 

^"^  'h>-  mini,,,,,,,,   i„    „,.,  '"■-'>'•""';' l"i.ryi,„-s',,,.„.,:^. 

'"'»«i->.''  ..f  tiK.  sc,  7„; ,  7  7  7"  ',""■"" "  '— Wc 

»■"■-  t„  cl„-,ct   thc.i,-  ,s,„de,        ,7s'  :,    "'7''"">''    ''■  "«■■*  "'-> 
l"-""I-"  >™.,ld  h.  a,  „„,7s77";    "'""  ""'  ""•"'■-•"'■  '->  the 

"-■  -"'".•..•<i.  Vet,  a  .,np^,^;:i  77  ::  ?7';7":!'  •■""""  ™- 

m.ncK.ni  since    ,«-,   „„j    ,,..,  '"•'  ,"   "'"  l"»l"i-y  „t  tlio 

."-•  lead.  sl„„„d  ,„  „n  "1  ,t'  ;,  ,7'   ""'■"":"  - ">■  '""k 

e..n»ideruti,mH    tl«..  ad,a,7    7      i     .         "''"  "■'""  "'^'  '»»e»l 

'"e  van.  t„  »..  „,„,  tl,      ,7  d    7  77"",'^  '"""''  ""«  be.,,  i„ 

•he  .""».  p,-..s,,.,,,,,.  ,,    ,7'.7     7^7f-''"-7eina!li„stanccs 

".e-m-c  i„  „.„,,„  ,„   f ;,  7„  ,7  7''"""-'-  """"■"-"■  "- 

'leal  ,cacl,i„j,.  and  tl,o  d.vd,  p  ,  7  '7'."'-';-™->'».  '"'e  prac 
'-y,  »itl„.„t  fcar„f„,„„.7  7  ,7^77;7^'"'  "7"'--'--  and 
'v.th  an  a„,pk.  and  a  jus,  ,v„-,M       >    ,  '  ""''""'"  '""'-■  '"et 

->.e.,i.s  „,,,.,,  dan,.„:'i:;d7:77l:f,.:'""..':",-  "■'■»'■  "■■'-'  "-■  -y 


an-4cr()iis  it  is  t 


en>and()ii   th 
'"'•  the  aver 


o  arouse  the  si 


Jier  advanee,  sh 


L-  couvietion  that  a  t 


uniburinj.^-  eonse 


|'<-'e]i   (lone,    i 


i«e  Anicriean  stud 


wo  session  course 


■owm^  how 
it-'uee,  and  to 


Uurin-  [hv   past   i 


n  spite  of  th 


(-'nt.      Hut  ii 


IS  sufificient 


t-'ii  years,    the 


L'  agitation  which  has  1 


«pite  of  all  that  has 


sac!   truth  ii 


5een  so  active 
lust  be  told,  that  a 


(. 


ii 


IJ 


\fvm 


'1  Wll  I  I  \M     OSI.KK.     M.      I). 

hirs^c  pcivcnUij^c   of  (locLors  arc  i^raduaUcl  annually  aflcr  onlv 
two  sessions  of  study. 

On  paper,  the  two  session  schools  almost  universally  demand 
three  years;  one  of  which,  it  is  stated,  may  be  with  a  physician. 
Now,  it  is  notorious  in  these  schools  that  a  larj^e  majority  of 
the  men  reccisc  the  dei^rce  at  the  end  of  the  second  collciic 
year,  and  it  is  just  as  notorious  that  not  5  percent,  of  the  cases 
in  which  a  preliminary  year  of  study  has  been  ])asscd  with  a 
phj'sician  is  a  hona-fuic  period  of  medical  instruction.  It  jirac- 
tieally  amounts  to  this,  that  a  man  enters  without  any  fair  ])re- 
liminary  test  as  to  elementary  education,  say  on  the  first  of 
October  of  the  present  year;  and  eij^htecn  months  from  date, 
or  rather  seventeen  months,  sometime  in  March,  1H91,  he  will 
be  let  loose  upon  the  commonwealth.  ICitihtcen  months  in 
which  to  master  one  of  the  hij^hest,  as  it  certainly  is  one  of  the 
most  difficult  of  the  professions  which  man  is  called  upon  to 
practice !  That,  gentlemen,  these  are  facts,  sad  facts,  each 
one  of  you  knows.  Yet  so  blind  do  men  seem  in  this  matter, 
s(j  wedded  to  this  pernicious  system,  that  I  have  known  physi- 
cians in  larg'e  practice,  able,  cultivated  men,  contributors  to 
medical  literature,  standini;'  hii^'h  in  the  esteem  of  their 
brethren,  permit  their  sons  to  follow  out  this  curriculum. 
Picture,  if  you  can,  the  mental  condition  of  such  a  , graduate:  an 
incoherent  jumble  of  theories,  a  chaotic  assortment  of  what  he 
would  call  practical  tips.  But  this  question  has  its  trat;ic  side. 
which  completely  overshadows  everythinj;-  else.  It  makes 
one's  blood  boil  to  think  that  there  are  sent  out  year  by  year 
scores  of  men.  called  doctors,  who  have  never  attended  a  case 
of  labor,  and  who  arc  utterly  is^norant  of  the  ordinary  e\eiv 
day  diseases  which  they  may  be  called  upon  to  treat,  men  ulin 
may  never  have  seen  the  inside  of  a  hospital  ward,  and  who 
would  not  know  .Scarpa's  space  from  the  sole  of  the  foot. 
Yet,  j;entlemen,  this  is  tlie  di.sj>raceful  condition  which  some 
.schcjol  men  have  the  audacity  to  ask  you  to  perpetuate;  to  'jon 
tiniie  to  intrust  interests  so  sacred  to  hands  so  unworthy.  Is 
it  to  be  wondered,  considerin^i;'  this  shocking'  laxity,  that  there 
is  a  wide-spread  distrust  in  the  public  of  professional  educa- 
tion, and  that  quacks,  charlatans  and  impostors  ])ossess  the 
land } 


lallv  after  only 


^^•>>'i-\i.     \i)|,Ki;ss. 

''"t   thr   hamWrain^  is  ,.„   the  u-Jl     ,i 
'H'en  read,  and  the  pn.phcev  in  eo         •        '    '"^^•'•i'-xiati,.,,  y^^^ 
^'  -'-is  not  the  vis    .n    . ■^  ,       , '       "  '"  """■"'  '""  ^■'"'"'nKnt. 
ten  years  in  searcel.-  a  Stat     H  k  r:''  ''  ^^^Ir'"^'-  ^'-^  -^i^n 

;''^i<in.donwV.nMhe  scho^  ;,:''•'"''''  ^''---'val  i 

^— n  in  thKs  co„„t,-v.  This  !""^'^^^•'•^^'■'"•t''-l>^.- 
^■<'nl,,cliti„n  h.uveen  the  eoik.pv^.  i?''"'"  ''''''"  ""'•^'^Ineted 
'-sionai  and  State  ,vst  a       ;':;""  ''"/"^^"  '^''—  "f  I>n.- 

p>--Mn  the  h^;: . ';::^^^^^^^^^ 

-•  ''V   the  State  soeieti  "      s,^  "     '""T"'  '^'  ^''^'  •--—•• 

^i^^KMvn  in  Xorth  Carolina.  Vir-ini,',  J/ ;■ '"'"^''^"  ""■■'^'"- 
"<>  ^''ffienlt3-,  and  u  eonstitutes  a^     i"  ''""^^"^^'-   >^--"ts 

measure   uiil    be  widelvad.rpted  ',.  ^^ '^''■". ''^ '-^  years  tin's 

^^  simple  meehanism.   and  ,,  elen-       i  V'?'"  ^^''^^"^^^^^'^^  i" 
1—  are   too  Hnmed.    an      U  ^ r    " i  "     ''""^'      ^'"^  ^1- 

preliniinarv  and  special    su  0   ns  '  ""  "'""■"'  '""  ^dueation. 

of  the  profession  In  each  S^uf  "  ^'■"'^"  ^^  '^'''"  ^'^  l--r 

>-^"^::;n::";:t::;:r:':s^  istr--- - 

.^...hiehn.avhedo;..     Oft:— ^^^^ 

--   pel    vent.,    were   n.  eeted     in,., ^■^^""'"<-d,  54,  „r 

creased   eonsidera]>lv   i     p  ^ti  ■  '"'  "''""   '"'^'^t  l.ein- 

-^  the  praetieal  branehes  --^"^'"afons  were  instituted 

^H<'^uu:"^'iJ;-rb.^;r::i!;^^^ 

-^ta,e  of  ^i.in.    he  1;:  ',;""'  '^'^--"^  the  .reat  ad- 
''^.   the    praet.ioners.\;::^:;;  ^ '::;;.--'"  ^"- the  hands 

•ninonty  rule  of  the  college.  -  ""'   '"^''    ^^'^ 

Theoretically,    there    e'ln    h, 


-<'-ni/.anee  of  all   matt 


perhaps,  thouo-h  of  this  I 
licalth  within  the  State. 


ers  relatiui-    t 


;^"""'^'''eiit.    which   should   t; 


medical   edueat; 


am  not  .so  sure,  of  quest 


ike 
on.  and 


I'ltonal   di\i 


■"^lons   which 


nii^i^ht 


as.senibly  di.slrict 


be   made. 


ions  of  public 
s.  or  other  ter- 


1 

I 
1 


\\ould   send 


1 

1 

m 

1 

1 

one,  or 


Wll  I  I  \M     OSI  KK,     M.     1). 


perhaps  two.  rtpivscntati\L's  Id  llic  Ixiafd  ( ilcpcmliiij;  iipnn  ilif 
pi-()fc'ssi()ual   po[)iilati()n   in  (.'acli  districl).      Tlic  electors  would 
be  eonslitiited  by  all  practitioners  irrespective  of  sehools,  which 
had  rej^istered  at  a  certain  date.      A    man  who  had  i)raetieed, 
even  w  ithoiit  a  diploma,  for  a  certain  time  would,  under  these 
eireumstanees,  ha\e  to  be  recoj^ni/.ed  and  permitted  to  re,i;isler. 
The  (lovernor  of  tlie  Stale  would   issue  the  first  warrant  for 
the  eleeti(ni,   which   would   subsetpiently    be  the  preroj4ati\e  of 
the  executive  of  the  board.      Ft  mij^ht  be  necessarv,  at  first,  to 
luue,  from  each  district,  members  returned  from  at  least  three 
of  the  divisions  which  at  present  constitute  practitioners.     'I'hc 
rei)resentation  sliould  be  per  capita,  tlie  number  of  constituents 
in  each  electorate  to  Ijc  previously  arranj^ed.      The  term  of  the 
board    should    be,    at  least,   four  or  five  years,  and  mcmbcis 
should  be  elij^ible  for  re-election.      Conducted  by  ballot,  there 
should  not  be  the  slij^htest  difTiculty  in   carryinj^-  out  such  an 
election.      There  would   be,   of  course',   active  cansassini;'.  and 
perhaps,    many  nominated   from   one  district.     Thou,i;h  there 
would  be  opi)ortunities  for  jjolitical  trickery  and  i^errymandcr- 
inj;-,    I   think,   on  the  whole,  it  would  be  found  that  an  election 
could  be  conducted  with  tolerable  ])urity.     The  universities  and 
schools  would  have  full  representation  on  the  board.     To  such 
an  organization,  I  believe,  mij^ht  be  intrusted  the  control  o*' all 
matters   relatini;-  to    medical   education  in  the  State.      It  would 
correspond   to  the  law    societies,  and  to  the  svnods  and  confer 
ences  of  the  various  relij^ious  denominations.      The  powers  of 
such  a  board   would  be  accurately  defined   by   lej;islation.   and 
should  relate  first  to  preliminary  education;  secondly,   to  tlu 
examination  and  rej^i.stration  (;f  candidates  f(jr  the  license  to 
practice;  and  thirdly,  the  control  of  all  matters  relatins^-  to  dis 
cipline  with  the  profession.     The  neces.sary  expense  would   be 
met — first,  1)y  the  fees  paid  by  the  candidates  for  examination; 
secondly,  by  a  small  annual  tax  levied  upon  all  res^istered  prae 
titioners.      Such  a  body  could  look  forward  hojK-fuUy  to  a  per 
manent  establishment  in  each   State,   with   buildin.ns  suitabh- 
equipped  for  examination,  and  with  every  possible  provision 
for  conductinj4,  in  an  orderly  and  .systematic  manner,  the  bu.^i 
nes^  of  the  ])rofession. 

The  first  important  function  of  the  board  would  be  the  re^ti 
lation    of    the    minimum    standard    of   education    reiiuireil  on 


^NM'AI.     .\!(|i|<l,Sf«, 

9 

'-si..n  should  say.  thn-.^I,  Usl^^^^^T'''\  '''''  ^"^^  •- 

study  of  .ncdidnc.     in    •         ,'      ,      'i  "'""T'^  "  "''"'  ••""■'  ^'-' 

l>c  so  with  us^    A  .,r  Vn L  '       ''"''^  "''>■  ^'"""^'  ''  ""t 

^"'"''"^'■'-  "t  I'ui'onn  tv  would  il>,,.  1 
wl>'^-l.   cannot  I,c  expected  in   the  sehools      T  •'"'" 

t'H'  prelinnnary  test  should  he  inde,  e  ent  ^"^^""'"^''--^  ^^ 
t-sional  n,en.  and  the  exanunatH::^  d  i^^";::  ""^  '''•'■ 
'IXlcrent  parts  o(  the  State.      The  period        \    \  "'^■'''    '" 

^-"  the  passing  of  this  prelin.!:  7  ,•:;>;:""[;'  '1^'^^' 
measure  would  etrectuailv  prevent  the  entr  ''''   '' 

^clucationwassuehthatu!eyeo.dd',^"      ^:l;;-^ 
with  the  subjeets  of  professional  studv  "'"'"^'>    •^''^^I'l'le 

The  examination  and  re.i^istration  of  emdidnt. 
statute  the  nH,st  important  function  of  tr;;!:;!;^  ^^''''''  ^"'"^ 

1  «■'!<-   sLRcuon   ot   examiners       'n,,, 

S.UU.  B,„„.ds  .,„  u,e  ,„„■..„■  »d„„„    „;,■;.  .'J    .  ',! '""f'""    '" 
"11  tl.c  il.niht  uhk-li  tlicv  l,,v,.  -iv  ,    ,1         ,         •    '•"«'-'ly  l«'wcl 

.■.,.",.,.«, nK.„ f.„. ,„M  .^ -T,  ■ : :;-"'■;"■  "—«■■.■)• 

H..C1,  ,.  IVdinK  exists  ,„„,  «,„„„„;„",        ""■,"'■"''■-"•" 
>hc'   board  as  c...„n,„cr  „„   hi.  .„       4  '  *'',  rT'''"""  ' " 

«"!'   •»■"   cxa.Mi,,,,,  „,   „,„.      ;,"';,;"  -""'""t-i.s.  and 

<';.»•,  d,c„,ist,,v,  pi,ysi„i„,.,  „„,,  pa.i„„  ;   ■ :     ■„  J"  !'"•••'; 

students  fr„„,  th.  lah,„.at„rie.s  .,V  ,„„•  fir  'chs    sc      "    ''"'''T' 


of  conduclinj^-  tii 
know  personally,  in 
would  entrust  with  tl 
ii'-y   students   in   the   tl 


ly  in  each  State  to  h 


e   necessary  test 


wor 


f.nind  men  fully  ca'pabli 


I   hi 


many  States  of  the  L' 


tve   the   h 


Kiior  to 


"inn,  men  to  whom  I 


le  utmost  eonddenee  the  examinati.m  of 
*  leory  and   practice  of  uied 


ii 


1 1 


icine,  and  1 


lO 


wii.i.iAM   oM.r.k,    \i.    I). 

dntil.t  not  that  in  surj^cry.  niidwitVrv.  ^■viutc(.I„j.v.  atul  in  the 
P^'lvKlot  sni)jcct  of  thurapcntics  nan  L(|nallv  ul)lc  in  these 
dcpartnients  uoukl  l)c'  forthcoming. 

ThL-rc  need  not  he  any  ditlicnlty  in  the  existing  dilferenees 
between  the  \an(nis  schools  of  practice.  All  students  would 
he  examined  in  the  i-rcat  primary  divisions,  anatomy,  physi- 
olo^y  and  chemistry,  and  so  also  in  ])atholo;4v  and  morbid 
anatomy,  ohstetrics.  and  in  operative  KyniceoloKv  and  in  medi- 
cal jnrisjjmdence. 

The  examinations  in  these  branches  woidd  be  imib.rni.  In 
therapeutics  only  would  there  hv  separate  tests  for  rej-idars, 
hom.eopathists  and  eclectics.  On  api)Iicati()n.  the  student  would 
ha\e  to  indicate  for  winch  of  the  three  he  wished  to  apply, 
and.  if  successful,  would  he  placed  ir  one  of  the  three  divisions 
of  the  State  Register.  I  am  free  to  confess  that  this  scheme 
may.  to  some,  seem  L'topian,  but  I  am  firmly  convinced  that 
the  majority  of  those  that  hear  me  to-day  will  live  to  see  Stale 
Hoards  ori^anized  on  tliis,  or  upon  a  moililicd  plan. 

With  the  third  funeti(m  (.f  the  Hoard,  vi/..  that  relating f. 
discipline.  I  need  not  detain  you  further  than  to  say  that  in 
any  etlective  act  there  should  be  penal  clauses .nivin^ authority 
to  pro.secute  irregular  and  unlicensed  practitioners;  to  remove 
for  cause  a  name  from  the  rc-isler;  anil  to  exercise  such  addi- 
tional powers  as  ini.iihl.  in  the  opinion  of  the  framers  of  the 
bill,  be  thouj^ht  justifiable. 

Now  the  entire  feasibility  of  such  a  scheme  is  illustrated  by 
the  professional  history  of  the  Province  of  Ontario.  Up  in 
1.SO5-6  there  was  a  Licensing  Board  appointed  by  the  State, 
which  deidt,  however,  in  examinations  only  in  the  ease  of  can 
didates  without  diplomas,  but  to  all  intents'and  purposes  it  was 
simply  a  Board  of  Rei^-istration  to  which  holders  of  dci-rees 
presented  themselves,  i)aid  a  small  fee  and  obtained''  the 
license.     The  schools  practically  eontrolled  it. 

In  the  .session  of  1.S65-6  the  profession  of  the  Province  sought 
incorporation,  and  the  Act  was  framed  which,  with  certain  iin 
portant  modifications,  at  present  remains  in  force.  It  practi 
cally  hands  over  to  the  profession,  throuj^h  th.c  elected  rciivr 
sentatives,  the  manai^cment  of  their  own  affairs  so  far  as  thc\ 
relate  to  preliminary  and  professional  cxaminatiims  and  cer 
lain   disciplinary  enactments.      In  spite  of  the  strenuous  oppo 


■\N'M'.\I       MHiKKhs, 


t  I 


Mil..,,  nn   tlicparu.f  nianvwh.,  fdt  tint  it  u-. 

•"K   thiuK   tiM.s  t..  I.,p  tlu.'i,m,o,-t.n  ,  """'  ''"«'•"' 

sutisfac-tion.  s„ch  as  a,v  al.nost  i„e      ^.i  '  ^  '^  ""  "" 

'-'•  '-'^^y-  -^tu-  .,  yeat-s  of  .xistcuv    h   ns     .        T    "'"''• 
t'--    e"ti,v    pn.t.ssi,.,,    ,„•    „,,   iVn,  ,;,,•"''''''''"''''■'' 

''■''-i''-'t.asopp.sit,.,, ,,  :  '^,:^7'•^''••^'•>•p- 
;''''-'i<-'-i.nwasavisitwitlMnv-  .J"  J'  ;r''"^^ 
tec   nx.iii   of  the   Iloiisi'     in    uh;  i    '        "^.^I*^"'  t"  t'le  n.minit- 

"-S  tlK.  healed  ,l,,s,„„c  with  rcfcren  .  :  „.  ,  :  "       ""''■ 

IK-ar  „,u„  the  umk;„  ll,f,„  ,  'Ulc-l,lc-,„u,tevc.„  l„e.,„lu 

';.'!-;::;- c:^\:;:;:.;r::;;;;';^xr'' '■-'-" 

'he   inevitable   „i.„   a   ,.e,.fee,K.  ,„„.  ,     ee  ,'  ','""  T'" 

s-sses  a  n.aK'nilieent  ee„„al  l^l.ildi,,,.  h       .iel,  ,       '"'""' 1","" 
examinaUcins.    with    „|K  ,,„    r  ,.  '"  "I'rUi  t.i  e..iHhiel  the 

iv"vi„eia,  ,.i,„-a; '  "!^:: ,:  •:::«■;»  ™-  -»'  .•<.—  i...-  a 

small  annual  cv'levi,..!  ^■«im,„ali„ns  ami  a 

ul'x  I w.;:^'"'"  ^^''  --'^«-^--  -i-  in  the  oth.. 

To    those    who  look    upon  such  a  schcnc  as  I  spe-tk  of  ■.  ■ 
I  t<.p>an.   and   ur^c  difficulties  on  acc<n,nt  of  the  d<^   h   s     , 
prcjuchces  and   wide  dissensions  existing  l.ctu^n  t    e  sd      r 
'   nuM-ht  say  that  the  condition  hc,-c  is  prt-tj  •   1  '• 

kind,    thouL-h   n..rh..„>. ....  .  P''^^tKallj  the  same  ,n 


'11  the   P^rilish    I'n 


ii^Ii   jK-rhaps  .i^rcatei-  in  d 


CK'"'-c. 


!'iat  which 


th 


ei-e  so  sueecssfullv  c 


•State  of  the  V 


iiion. 


•ninces  i)nor   to  ,S66.     What  has  1 
c  eciually  well  accomplished 


existed 


111  b 


'cen  done 
in  e\erv 


•:i 


li 


'  vi 


12 


WII.MAM     OSI.KK,     M.     I). 


rhc  -rcuL  -am  is  the  pulilic  o-iuirantcc  tlial  when  a  man 
has  received  the  lieense  to  practise,  he  hai,  at  any  rate,  thr 
elements  ct  a  solid  education;  that  he  knows  the  structure  and 
I  unctions  of  the  human  body;  and  that  he  is  capable  of  mect- 
ini4-  the  ordinary  enieri^encies  of  professional  life.  Such  a  pl-in 
removes  the  irresponsibility  of  the  schools,  establishes  a  uni- 
form curriculum  of  studies  in  each,  and  exacts  a  minimum  time 
fca-  theoretical  and  practical  work. 

The  difference  is  simply  this,  that  under  our  present  system 
independent  and   irresponsib! :   schools   have  the   upper' hand 
and  dictate  terms  to  the   profession  and  to  the  public,  and  d(. 
whatever  they  please.      With  an  organized  profession,   thn-u^h 
Its  representatives  m  session,  the  schools  take  the  sec(md  place 
—they  exist  for  the  profession  and  the  public.     'Hiere  can  be 
no  (piestion  as  to  the  ^rcat  superioritv  of  this  method       It  is 
essentially   democratic,   and  should  commend    itself  in   everv 
particular    to    the  profession  of  this  country.      It  is  infinitely 
superior  to     he  .second  method  carried  on  at  present  in  many 
of  Uie  Slates,  althouj-'h  the  Examining-  Boards  nominated  by  the 
Governor  or  the  societies  are  better  than  unrestricted  registra- 
tion.    W  hile  the  interests  of  corporations  are  fully  represented 
in  this  system,   they  have   not  the  oxershadowin'u-  power  such 
as  uas  -ranted   m   (ireat  Britain  ])y  the  recent  Act  in  which  it 
seems  almost   ridicuh.us   to  think  that  only  six  representatives 
from  the  profession  at  larRe  found  a  place  in  a  Board,  and  this 
number  Knul-iuMly  granted  as  a  privilege,  not  as  a  riMht 

It  does   not   do.    however,   to  underestimate   tlie  difficulties 
which  liave  to  be  encountered  in  any  attempt  toori-anize  these 
Boards.      It   may   l)e  premature   in  many  States.     'The  pn.fes 
sion,    I  have  iTcciueiitly  heard   it  stated',   is   not   ready   for  it 
This,  from  my  own  (jb.servation,  I  should  doubt       I  bJlievethe 
g-eneral  body  of  the  i^rofcssion,  when  it  fulb-  understands  tlie 
question,   cannot  but  aurec  that  the  method  is  in  reality  a  safe 
one.      I  am  sure  that  the  public,  through  the  press,  will  heartiK 
concur   in  any  plan  which  will  guarantee  that  the  praetitioner's 
to  whom  they  entrust  life  and  limb  shall  l,e  educated  men 
( )p[)()siti(m  will  be  strongest  on  tlie  one  hand  from  tht 


which  1( 
their 


askance    it   any    measure    likely   to    interfe 


llools, 
re  with 


h 


prerogatives,  and  on  the  other  hand,  the  members  ..f  tl 


(unieopaiJnc  and   eclectic  fralernit\ 


11  ■ 


not   uniiaturailv   di'eat 


Kil  wlicn  ;i  iiuiii 
at  any  rate,  the 
lie  structure  and 
-•apable  of  nicct- 
fe.  Sucli  a  plan 
stablishes  a  uni- 
i  niininium  time 

present  system 
he  upper  hand 
-•  puhlie,  and  do 
L'ssion,  tlirouj^h 
he  second  jjlace 
'J' he  re  can  lie 

method.      It  is 
itself   in   e\ery 

It  is  infinitely 
resent  in  many 
minated  In-  the 
ricted  rei;ist ra- 
lly represented 
ino-  i)o\\er  such 
iVct  in  wliich  it 
representatives 
l'5oard,  and  this 
is  a  rij^ht. 
the  difficulties 
ort^ani/.e  these 
The  profes- 

ready    for   it. 
I  believe  the 
ulerstands  the 
1  reality  a  safe 
;s.  will  heai'tib 
-  practitioneis 
ated  men. 
m  the  schools, 
interfere  with 
embers  of  the 
turalK-    dreail 


ANNTAI,     ADDRISS 

lest  in  any  such  arraiio-cmcnt  ->  fnii  ,„  . 

""t  be  meted  them.  "''"''"  "^  J"'^^'^"^^  ^^-"l^' 

-The  antat^onism    of  the  schools   is   not     I   b,.i; 
'  "  1-   eifectual  they  would  have  to  be       Ue  7'   T""'" 

that  many  of  the  F-.enDi.v  ,        "'^^^''      '^  '^  notorious 

••;  l.i..l.c.,-  s,a,„,a„,  „f  ..a,„i„.,.i„„         ':,',„  ;,;;;""  '"  '""^  '•■"• 
>li'.-.I  fairly  will,  th,m  i„  a  muttcT  „  ,       ,  /■  •     """""'  '" 


-i<"..»i«fee  plainly  t,,.!,-  H„„„,  „■.*;':,::;;::::■■;:; ;;-' 

same  as  our  own.  aie  the 


I  i 


'I 


1 

1^"'  1 

: 

f 

1 

1 

^ 

i  ^ 

M-' 

■'  3 


ii 


'  s 


III 


il^v/l 


^QUANIMITAS: 


VALEDICTORY   REMARKS 


TO  THE  GRADUATES  IN  MEDICINE  OF  THE  UNIVERSITY 
OF  PENNSYLVANIA,  MAY   ,sT,  ,S8,. 


BY 


WILLIAM  OSLER,  M.  D., 


PKOPKSSOR    OF    MEDICINE,  JOHNS   HOPK 


INS   UNIVERSITY,   BALTIMORE. 


PHILADELPHIA: 
PRESS  OF  WM.  F.  FELL  &  CO., 

Nos.  1220-24  Sansom  Street. 
1889. 


I 

if 

i 

-      :       ■  \ 

^    a 

■  ■    i    ^ 
1^ 

•  ;■ 

I 


I   i 


1 1 


II 


m 


:-| 


m 

■ 

^^^..Ji 

^ 

/EQUANIMITAS. 


an.flcmnu-Cnstom,  wl.icli  lies  upon  us  with  a  u-elL^ht 
heavy  as  frost,  has  nuulo  even  stale  to  .nany  those  tZ£t 
annual  ceren.omes.     To  you  at  least  of  thase  .veseTu^ 
houl.l  have   the   solen.nity  of  an  ordinanie-ca  Ld  as 
you  are  tins  day  to  a  hi.d.  dignity  and  to  so  weig    y  an 
office  and  charge.     You  have  chosen  your  Genfu  ^anS 
have  passed  beneath  the  Throne  of  Necessity,  ami  w   1. 
the  voices  of  the  fatal  sisters  still  ringing  in  your  " 
will  soon  enter  the  plain  of  Forgetfuh.ess  and  d    nk  of 
the  waters  of  its  river ;  but  ere  you  are  driven  all  ni    Lr 
of  ways,  hke  the  souls  in  the  tale  of  Er  the  PaniphyZ  ^ 
It  IS  my  duty  to  say  a  few  w^ords  of  encourageme  it  and  to 

jouri^:;:'  "^ '"  """^  ^^  '^  '''''^'''  ^^^^'^--^  -'  "'u: 

I  could  have  the  heart  to  spare  you,  poor  careworr 
survivors   of   a   hard   struggle,  so  "lean   and  p        a" d 
eaden-eyed  with  study;"  and  my  tender  mercy,  whic 
has  been  ever  towards  you,  even  now  extends  so  f^^r  as  to 

wS  will  T'^"" ''''' '''-' '' ''''  ^^-'^  «^  ^^--"t: 

which   Mil   make  or  mar  your  lives,  two  which   may 
contribute  to  your  success,  or,  more  important  to  many 
help  you  in  the  days  of  failure.  ^ ' 

In  the  first  place,  of  all  q  mlities  in  the  phvsician  or 
surgeon  no  one  takes  rank  with  imperturbability,  and  I 
purpose  for  a  ew  minutes  to  direct  your  attention  to  thi 
most    essential    l,od,ly   virtuo.     ilaply  those  of  you  in 
whom  It  has  not  developed  during  the  critical  scenes  of 
the  past  month  may  catch  a  hint  or  two  of  its  importance 
perhaps- a  prescription  for  its  preparation.     It  means  cool- 
ness and  presence  oi  mind  under  all  circumstances,  calm- 
ness amid  the  storm,  clearness  of  judgment  in  moments 
of  grave  peril,  immobility,  impassiveness  or,  to  use  an  old 
i^nglish  and^nost  expressive  word,  phlegm.    It  is  the 

*The  Republic  Book  X. 


u 


II 


\\i 


i 

u 

:, 

''■'"' 'i 

ul 


«,l 


m 


f  1 1  >U'^^- 


m   :| 


I  •' 


w 

/ 

■'^1 

u 

t 


•juahty  of  all  others  which  is  appreciated  bv  the  laity 
thoujjh  often  misunderstocl  by  them  ;  au<l  tlu,  physician 
wlio  has  the  misfortune  to  grow  up  without  some  share  of 
It,  who  betrays  indecision  and  worry  and  who  shows  that 
lie  IS  flustered  and  flurried  in  ordina.y  emergencies  loses 
rai)idly  the  confidence  of  his  patients. 

In  full  development  as  we  see  it  in  some  of  our  older 
colleagues  it  has  the  nature  of  a  divine  gift,  a  blessing  to 
lie  possessor,  a  comfort  to  all  who  come  in  contact  with 
hmi.      You   should    know   it   well,   as   for   years   there 
have  been  before  you  several  striking  illustrations   the 
example  of  which  ha.  I  trust,  scored  deeply.     Largelv  a 
bodily  endowment,  there  are  those  amongst  you,  I  regret 
to  say,  who  may  never,  owing  to  congenital  defects,  be 
able  to  acquire  it.     Education  will  do  much,  and  with 
practice  and  experience  the  majority  of  you  may  expect 
to  attain  to  a  fair  measure.     The  iirst  essential  in  the 
development  of  imperturbability  is  to  have  your  nerves  well 
in  hand.     The  physician  or  surgeon  who  under  any  cir- 
cumstances, no  matter  how  serious,  allows  "his  outward 
action  to  demonstrate  the  native  act  and  iigure  of  his 
heart  in  complement  extern,"  in  other  words,  who  shows 
in  his  face  the  slightest  alteration,  expressive  of  anxiety 
or  fear,  has  not  his  medullary  centres  under  the  highest 
control  and  is  liable  at  any  moment  to  disaster. 

I  have  spoken  of  this  to  you  on  many  occasions,  and 
have  urge<l  you  so  to  educate  your  nerves  centres  that  not 
the  slightest  dilator  or  contractor  influence  shall  pass  to 
the   vessels    of  your  face   under  any  professional   trial 
^i-ar  be  it  from  me  to  urge  you,  ere  Time  lias  carved  with 
his  Hours  those  fair  brows,  to  quench  on  all  occasions 
the  blushes  01  ingenuous  shame,  but  in  dealing  with  vour 
patients  emergencies  demanding  such   should   certainly 
not  arise,  and  aii  inscrutable  face  may  prove  a  fortune 
In  Its  perfect  and  true  form  imperturl)ability  is  indissolubly 
associated  with  a  wide  and  ever  increasing  exi)erience  and 
an   intimate  knowledge   of  the  most  varied  aspects  of 
disease.     Nothing  that  can  happen  disturbs  the  mental 
eciuihbriuni  as  the  conditions  are  familiar,  the  possibili- 


ties  manifest,  the  course  of  nclion  olwn-     'n  ■ 

quality  is  liul.le  f,,,,,,  i„  „„  „,„'"'■     ['""  l""'""^ 

«n.ltl,o,..„er„l.eeus„,i™Tf  :'r:;:t',''''''^*i''- 

"gainst  the  profession  l„„  1,,,,  i,  r  ,  , '"'  '"'""S'" 
^.■tain  n,eas,  ro  of  inscil  .  /""'"I""™-  N'ow  a 
but  a  positive  nooes:;  i', '  ,";,:■'.""  ";•"'"•'«" 
m-t,an,I  in  eanyin.'out  -le.i..  e  ;  .l:,:"'";  •':"'«- 
sensil„l,ty  is  ,loui,tless  a  virl,,,.  „|-  M ll  ,         "'" 

interferes  with  steadiness  of  in,  *'      f"'  '""  ''  " 

a  ealiousnoss  .hie,,  ti,!:!:!, t^  V/  ,:;;  "-;'^-'7'; 
and  goes  ahead  regardless  „f  n'linor  e  ,k        V  '"'' 

ferable  wisdom  in  the  w„rl<ingl;  , „      '  "';i''''"'' '"  '"" 

rmtivate  then,  genllemen    tint    n  '  "*"■■■ 

obtuseness  wWol/udni  i  e  'hi  -j  t  m",  I','™"'"  "' 
ces  of  praetieo  with  tirn.ness  anlfe  ,  g!.' Z^'  ^".f;;"" 
same  t,me  harden  "  the  Innnan  J.eart  hv       i .,  t     "' 

as  injportant  as  in;pertnlb\'  ^C  rs^ntr'^'ft ''*''° 
recall  to  your  minds  the  incident  r  h del  ,f  :,  "V"f 
men  and  wisest  of  rulers,  Antoninus  P  ',  t,  h!  ,  "^ 
dying,  n.  bis  home  amidst  the  Apenni^    ,1^   '        ^^ 

2  '"e  Philosophy  of  life  i„ ,,  „,\:;;;;.'  ,    ;,;;;;;;• 

A    tor  hnn,  abont  to  pass  /„„„„„■„  ,„.;„   ,"2™  jf^' 
/laming  rampart  of  the  world    «„   r  "«»«',  tlie 

«»tl.o's    spi,!d,o   a  calm  em  raiir't'b  '■'■;"■  "n' 
attitnde.    How  <lifflcult  to  at  ain    v  M,  „•  ■'" 

™o<»ssasin.ii„.,  Xatn.i tcin^;::;::, r^:^. ^ 

uo  Willi  Its  ilovelonmpnf    Imf  .■   ,,1         1         ,    , 

roiation  to  onrfciii.  ::;,:;:::;:,:;'■  ;-^*:;^;om 

an  >nd,spensal,le  factor.     One  of  the  first  e  s™^  1,  i 
oou„„g  a  good-n„tnre.I  e,,„ani„dty  is  not   o  e"  cc  ,00 
n  .ch  of  the  peo,,le  amongst  whom  yon  dwell     i  "1° 
.  e,  go  ^bnt  wisdom  lingers,"  anj  the  average  dfcl 

trT'iri;::^"!^'?  ■»«•-' »-  -hit  m^or:::: 


in   the  old    Romans,   wlioiu   L 
credulity  which   made   tliem    fall 


juacks  of  the  time-  sucl 


ucian   ^"oiir^j.a    for 
easy       ;tinis   to   the 


whose  exploits  male 


as  the  notorious  Alexande 


f    t 


:f 


e  one  wish  that  his  advent  had  been' 


.  t 


delayed  some  eighteen  eeiituries.  Deal  <,^eiitly  then  with 
this  delieiuusly  eredulou.s  old  hiiinau  niiture  in  wliieh  we 
work,  and  restrain  your  indignation,  when  you  tind  your 
jH't  jmrson  has  triturates  of  the  lOOOth  potentiality  in  his 
waistcoat  pocket,  or  you  discover  aeeidentally  a  case  of 
Warner's  Safe  Cure  in  the  bedroom  eupboard  of  vour 
best  patient.  It  must  needs  be  that  otfenoes  of  this  kind 
come ;  expect  them,  and  do  not  be  vexed. 

They  are  curious,  odd  compounds  these  fellow  crea- 
tures, at  whose  mercy  you  will  be;  full  of  fuds  and 
eccentricities,  of  whims  and  of  fancies.  I  do  not  mind 
telling  you,  (Jentlemen  of  the  graduating  class,  a  secret 
which  I  would  not  for  my  cap  and  gown  mention  in 
public.  It  is  this:  the  more  closely  we  study  their  little 
foibles  of  one  sort  and  another  in  the  inner  life  which 
we  see,  the  more  deeply  is  the  conviction  borne  in  upon 
us  of  the  similarity  of  their  weaknesses  to  our  own,  until 
we  weary  of  a  uniformity  which  would  be  intolerable 
did  not  a  Imppy  egotism  render  us  oblivious.  Hence  the 
need  of  an  infinite  patience  and  of  an  ever  tender  charity 
toward  them;  have  they  not  to  exercise  the  same  to  us? 

A  distressing  feature  in  the  life  which  you  are  about  to 
enter,  a  feature  which  will  press  hardly  upon  the  iiner 
spirits  among  '  you   and   rufHe  the   equanimity,  is   the 
uncertainty  which  pertains  not  alone  to  our  science  and 
art,  but  to  the  very  hopes  and  fears  which  make  us  men. 
We  aim  at  the  unattainable  in  seeking  absolute  truth  and 
must  be  content  with  broken  portions.     You  remember  in 
the  story  how  the  Egyptian  Typhon  with  his  conspirators 
dealt  with  good  Osiris;  how  they  took  the  virgin  Truth, 
hewed  her  lovely  form  into  a  thousand  pieces,  and  scattered 
them  to  the  four  winds;  and  as  Milton  says  "from  that 
time  ever  since,  the  sad  friends  of  truth,  such  as  dost 
appear,  imitating  the  careful  search  that  Isis  made  for 
the  mangled  body  of  Osiris,  went  up  and  down  gathering 
up  limb  by  limb  as  they  could  find  them.     We  have  not 
yet  found  them  all,"  but  each  one  of  us  may  pick  up  a 
fragment,  perhaps  two,  and  in  moments  when  mortality 
weighs  less  heavily  upon  the  spirit,  we  can,  as  in  a  vision, 


Ill  a  vision. 


see  the  form  divin,.    i.Kf  „^  .. 

'Vn-.n,w.(.  ^"''  "'""^^'''^''^t'"'*' I'oni  a  lo,.,sil 

'(   lias  bc'cii  said   Hmf   ;.,  .  , 
<^l.iHly  ex..vis.d  iMc.na.l'';:T'''r  '""■"•'• '"'">- 

;l-turbs  our  nu.ntal  pladdi^.  I  ;  ,.^;7i;''''''V'''^'- 

cures,  gettin^r  ,uh|  spcMdinfr  vn„      ''"'"  '"   I"'"'"^'«'-i«>naI 
Hwuy,  tl.a  tlu.e  is  no  ,      :    i       . '''^  ^V^''   J-arts  ^iv.,. 

/tissadtotinnkthatiori;;;7X  ;;"'•''• ''^■'"^• 

clisapiKHHtniont,   porhaps  failure      V         ^'"'^■^' ''^  "' «tore 
course,  10  escape  from  the  ca         i,,.  •'':'""   '"'l'^'  «f 

professional  life.    Stand  un  '        """^""^  ^^'^''^'^'''t  ^o 

Your  veiy  hopes  nu  y  hZ  "         1  '''"  '^^''"^'  ^^'"  ^^--^t- 
all  that  was  iiL  and  d^M^^pT -"V'"  ^^^''^' '^^ ''^ 
ford,  and,  hke  him,  you  m  .    ,    \Tt     \  ''  ^'"'  '''''''' 
niglit  alone.     WeH  fm-  vo     ?f  '  '''"^^«'^'  "^  the 

-teney  lies  the  viet^  -  I/Ui:;,:'''-^^^'  • '"'  ^^^  '"  ^- 
the  wished  for  blessino  I  '  ./  i ''"''"''«"  "^"^^  ^'^'"^' 
«trug^-le  with  defeat  and  t  ?''''  ^"^^  ^^'^''^  ^^  a 

bear/  Well  for  youhu't'r'fr^^^ 
aeheorfiil.pi,,,,^;'^     ;i     3^;-ballh^ 

"iVon,  ourdesolation  on  y  do        ^ul/rr    f  '^^""^'^""^^« 
oven  with  .lisaster  aluM    and   .  ^''  ^^'^■'"•"    ^'^'^ 

■sn.ile  and  with  the  he  u   T\      W  '""""'''"*,  faee  it  with  a 
tl-  blow.  AncH     .     i;^    ::^,"^'-'  ^''-'  ->-l.  beneath 

even  when  failures  em    et^,^^^^^^^^ 

iH'fore,  cling  to  your  Zl  '         -1    ^  ''''''>'  '"^^'^^  ^^'i'^xl 

tlu.  1)  rk  T<>  2  !"K'^:,^"V'^^C''''<^^l^oland  before 


ehall 


t^^nge,  and  cahnl 


■er,  set  the  slug-horn  to  vour  I 


It  has  h 


y  a\\-ait  the  result. 


IpS,  l)l(>w  tlu 


souls, 


>cen  said  that  "In  nafi 


and  what  is  this  but 
you  to  bear  troubles  and  to 


jxificncc  ye  shall 


win  your 


an  equammity  which  enab] 


rise 


as 


superior  to  the  trials  of 


•M 


;  k 


lifo.  S«mu,  %  us  ynii  slmll  do  besido  all  \V(it(>rM,  T  can  but 
wi.sh  tbiit  yoij  may  iviip  the  promi.sod  blessing  of  (|uietn<.'.s,s 
and  of  assuninco  forovcr,  until 

"Within  this  liCf, 
TliotiKh  lilttd  o'er  itH  strife," 

you  may  in  the  j^i-owing  winters  glean  a  little  of  that 
wisdom  wliieli  is  pure,  peaceable,  gentle,  full  of  mercy  and 
good  fruits,  witiiout  partitdity  and  without  hypocrisy. 

(Scnilcmcn — The  past  is  always  with  us,  never  to  b(* 
escaped;  italone  isentbn'ing  :  but  amidst  the  changes  and 
chances  which  succeed  one  another  so  rapidly  in  this  life 
we  are  apt  to  live  too  much  for  the  present  and  too  much 
in  the  future.  On  such  an  occasion,  when  the  AhiKt  Mater 
is  in  festal  array,  when  we  joy  in  her  growing  prosperity,  it 
is  good  to  hark  back  to  tluf  olden  days  and  gratefully  to 
recall  the  men  whose  labors  in  the  past  made  the  present 
possible. 

The  great  possession  of  any  University  is  its  great 
names.  It  is  not  the  "  pride,  pomp  and  circumstance  "  of 
an  institution,  not  its  wealth,  nor  t!ie  number  of  its  schools, 
not  the  students  who  throng  its  halls,  but  the  mat  who  have 
trodden  in  its  service  the  thorny  road  through  toil,  even 
throu.h  hate,  to  the  serene  abode  of  Fame,  climbing  "like 
stars  to  their  ajipointed  height."  These  bring  glory ;  such 
bring  honor:  and  it  should  thrill  the  heart  of  ever}- 
alumnus  of  this  school,  of  every  teacher  in  its  faculty,  as 
it  does  mine  this  day,  reverently  and  tliankfully  to  recall 
such  names  amongst  its  founders  as  Morgan,  Shippon  and 
JIusli,  and  such  men  amongst  their  successors  as  Wistar, 
Physick,  ''uton  and  Wood. 

Gentlein..     "f  tJie  Faculty, — Nohlem'  oblige. 

And  th'^  -u>  'iU.'ity  ,,i  the  past  touches  us  to-day  in  the 
freshness  oi  «o.  ow  at  the  lo--^'  of  friends  and  colleagues, 
"  hid  in  deivths  u  twle.ss  nighw'  We  miss  from  our  midst 
one  of  your  l.>est-known  instructors,  by  whose  h^ssons  yoii 
have  profited,  and  whose  example  has  stimulated  many. 
An  earnest  teacher,  a  faithful  worker,  a  loyal  son  of  this 
University,  a  good  and  kindly  friend,  Edward  Bruen  has 


9 

>V()  ri.c.rn  fo-duy,  ul.s,,  win.' 

f'onor  an  ).„n,.n.,|  „an„.  ,.,.  ' '!  '"""  "''"'  '"'H'  U'itli 

^"■'•«x   nm    ill    I,,       ,,^,,,,      V;,  '^"••''  ""•".■..sSa,n,„.MV. 

J^e.1  his  career.  ^^  ""  '  ""^"'^^0'  wJ.ich  d.aracttT- 

lV.r.su,mlly  I  mourn  fho  l„ss  „f  .. 
««  't  <athor  the  n.an  fVo.n  2  '""^''"I'K  dear  fo  „„. 

r-.ive,l  inspiration         "t.'r'''""  ^'"'"  ""■-'"-• 

J^  H,re  arc  tho.se  pre.sent  who  uil    f    "!  '^'^''^'-^'^y'^u  to-,|av. 

T''*'"  f  '^'^y  that  to  have  k  0        .>'     "  "°  ^•^•"^'^^^">.tioM 

'T.  ''^"^'^-^  -^'I  truest  ontoT    .:'''"  '^•^^^-••'  -'^  i" 
edition  :—  ''^  tlie  phra.se,  a  liberal  e,!,,. 

''Whatever  way  „,v,,av,s,p,n„, 
el   a,ul  „.,.,,  t,,„-  ,„,, 

'™*o  ,1,0  ,„o„„„i.4„..;  ,2  „"'{.,"";"  "'*■• '  '""«- 

"■«''»  liavo  thought  eliit  n  ,1  '''■'■  '"'*•''  ■'■"•    Ono 

'^  lover  of  hi.,  ,.rofeii„„     .    ;     ,      »'«"■'»•">»«  -io  dear  l„' 

I  -y,  .hat  ,I,e  Herc,,lorp  Cof  !  "'«'',' ''""  ""•"«''! 
l>ore  boon  ro,icl,od.  H„t  it  1,  „  f  f  """'■"  ""'Wti.m  i,„d 
to-day  I  .ever  ,„y  oon-looH^t  ,,  „  r,'.^"  "*"'«'•  "^ 
'  m.i  o„co,  sentlomon,  in  „  if  ,  '  "'««ty.  Afore 
•'-".g  of  friend.  I  ,;„:  L;\  ;'■''"•  "-  ,.rioeK, 
"'"ci,  no  „.ord«  oould  oxnro,.  M  ft  '"  '*'"'""»  "' 
-').-  H  i,  „.,•„,  ,n„  now  T,,  'V-^^'r  °f  "'.vl,oart, 
gratitude  ivoll  up  from  n,>  inn  ''"""  """'"'"its  of 


il 


,  <1 


10 

at  every  step  during  the  past  five  j^ears.  A  stranger,  I 
cannot  say  an  alien  tanong  you,  I  have  heen  made  to  feel 
at  home — more  you  could  not  have  done.  Could  I  say 
more?  Whatever  the  future  may  liave  in  store  of  suc- 
cesses or  of  trials,  nothing  can  blot  the  memory  of  the 
liai)py  days  I  have  spent  in  this  city,  and  nothing  can 
(jueneh  the  pride  I  shall  always  feel  at  having  been  asso- 
ciated, even  for  a  time,  with  a  Faculty  so  notable  in  the 
])ast,  so  distinguished  in  the  present,  as  that  from  which 
I  now  part. 

(Icnilcmrn, — Farewell,  and  take  with  you  into  the 
struggle  the  watchword  of  the  gootl  old  Roman — jEqua- 
nimitas. 


X  stranjTcr,  I 
mado  to  feel 
Could  I  say 
store  of  siic- 
miory  of  the 
notliiiig  can 
g  been  asso- 
table  in  the 
;  from  wliich 


DU   into   the 
nan — ^Equa- 


il 


-i 


iM 


Ml 


I  I! 


» 

Il 

; 

H 

1           , 

III  II I 


1 


i 

vi 

■-:     IS               1 

•d 

bl               ■ 

Xo  I 


,         .        ,  Extracted  from  tlie 

Amencan^ournal  of  ti.e  Medical  Scie 


^..^^^^^^leai^enees  for  September,  1889. 


>*(LV 


hr_r  ' '  « 


'""'"!!i'r;'-""-' «,..™,,,,,,„„„„,^^_ 


889.] 


XAH  ATROPflv 
iPULO- 


•TIMORE. 


'»"gue  to  the  heart  Ind     "  '^''  ^^'^  °^  ^'^^ 

th-se  points  the  so -ca  Ld  7'^'""'  'ying  between 

fo"nd,  or  even  in  rareln'tn      "'  u"'""^^  '"^^   I^^ 

Th)roidaI  growths  a!o'  '  '""^'"  ^'^'^  ^^^^•l^^^- 

."ost  -mnfoniy  sub  sternar-'   ""''""    ""   ^^--' 

;--f  directly ;i",'hl™d"  'oTt^^"'  ^"'  ^«"- 
I'ave  been  described  CVirchmv   ,.      l^'"'''  ^  ""'"ber 

More  rarely  tumors  develop  frointrl^^^^^^^^^^^  ""'■  ^^■ 
or  aberrant  bits  of  a  late  af  W  '\^  ^'^^P^'"  portions 
chest,  forming  large   n  ra   h        '"^  '"''^"^  '"^«  ^'^- 

A  most  remarS  ^'ie  r; '^  ^'T''- 
{Pn^ger„,e^.    ^^..wT^    m'^""*^^  by  Dettrich 
-nan,  aged  sixty,  X^' .^^..^^.^f  7).     In  a 
'^"h  cough  and  hiemoDtvsi.H  °'  ''''"^  ^'"^<^ 

•Oe  greater  part  of  t^e'^g        raT  f°""''  ^'"'"^ 

'--ve,itwai::rs;:,n:H:-,:s 


lished  by  Dr.  B.  Sachs.     >ow  y 


ort:  Men ,,11 


ficultie.s  have  been 
ing  upon  the  situa- 
ave  been  described 
■u  wo  have  scarcely 

.^ing  all  the  forms 
gressiva— of  which 

srtrophic   muscular 


which  atrophy  and 

Jrs  in  one  grouj)  and 

•recedes  for  months 

not  surprising  that 

Gowers,  however, 

ly  occur  in  families, 

hie  disca.se. 

hy  that  the  greatest 

ig  forms  have  been 


le,  and  of  Landouzy 


00th. 

plan  in  (li.<re,uarding 
.mder  the  designation 

University  Hospital 
ler  has  reoentlv  been  pub- 


k 


i 


I 


'   h 


2  OSLEK, 

lobe  of  the  thyroid.  The  cyst  had  yellowish-hrowi 
contents  and  contained  cholesterin.  Kretscln 
{Wiener  ined.  Wochcnschrift,  1877)  describes  a  sai 
coma  of  the  thyroid,  four  and  three-quarters  inclio 
in  length,  which  formed  an  extensive  mediastiuai 
tumor  jmssing  to  the  level  of  tiie  ninth  dorsal  \ci 
tebrae. 

In    the    following    case.    No.    702,    Post-mortem 
Records,   Montreal  General   Hospital,  there   was 
tumor  similar  in  situation  to  I)ettri(-h's,  though   iK.i 
so  large : 

The  patient,  a  woman,  had  died  with  .symptoms  (H 
purulent  bronchitis.  There  was  no  special  ema<  ia- 
tion.  Occupying  the  top  of  tlie  left  thoracic  cavil  \ , 
outside  the  pleura,  was  a  mass  the  size  of  a  laru'i.' 
orange,  closely  attached  to  the  oesopliagus.  The  ai.  h 
of  the  aorta  lay  on  the  right  side,  the  left  subclavian 
passed  directly  over  it  and  the  left  carotid  pa>M(l 
just  beside  it.  There  was  no  sjjecial  connection  w  iih 
any  thoracic  organ,  though  filling  completely  liic 
top  of  the  left  thorax.  There  was  a  large  brondir- 
cele,  the  left  lobe  of  which  was  in  contact  with  ilk 
tumor  and  could  not  be  isolated  from  it. 

On  .section,  it  consisted  of  \  series  of  imperfo  tlv 
separated  cysts  containing  a  yellow-brown  ihiid  in 
which  were  plates  of  cholesterin.  The  upper  jiari 
of  the  tumor  was  firm  and  hard  ;  some  of  the  sepia 
had  calcified,  others  had  a  fibro-cartilaginous  ((in- 
sistence. 


Mi 


The  relations  of  tliis  mass,  its  anatomical  <  harai  ter, 
and  the  nature  of  the  contents  of  the  cysts,  ideiui(  a! 
with   that  which   is   found   in  so  many  ca.ses  u\  did 


\<z^l 


.         .  Extracted  from  the 

American  Journal  of  flip  Aro,i;„-,i  c  • 

^«'_o^e^Medicaj  Sciences  for  September,  1889. 


LAli  ATROPHY 
VPULO- 


t  had  yellowish-brown 
lolesterin.  Kretscln 
[877)  describes  a  sai 
tiiree-qiiartevs  inclu^ 
extensive  mediastinal 
the  ninth  dorsal  vei 

o.    702,    Post-niorteiii 
^^ospital,   there   was 
)ettrieh's,  though  nm 


died  with  symptoms  m 
?as  no  special  emacia- 
le  left  thoracic  cavil  v, 
5S  the  size  of  a  lari^c 
oesophagus.  'rhear(li 
de,  the  left  subclavian 
le  left  carotid  passal 
)ecial  connection  with 
illing  completely  the 
was  a  large  bronc  lu.- 
LS  in  contact  witii  ihi 
^d  from  it. 

I  series  of  imperfci  tly 
yellow-brown  fluid  in 
rin.  The  upper  jiari 
■d  ;  some  of  the  sciita 
)ro-cartilaginous  1  mi 


anatomical  cliarai  tcr, 
of  the  cysts,  identical 
so  many  cases  nl'  uld 


'NTRA-TUOKACIC    GROWTHS  3 

J"  <onnection  with  the  case  r.f  K    !   \ 
"•'■erred  to,  a  somewhat  r„n  ^retschy,  above 

l'v'"e  a  fewvea      a'       }  '''^ 
A''/-/..  Vol.  -r,  ,88%7  ''  ''"'"'"'  ''^'^'"^ 

l"eathmg  and  the  cuiestinn   nV  .  ^'^^^   difficulty  in 
-l-;ed  but,  as  the  d;  Sa  becam'e  ".'f  °^°'7  "^^  ^°»- 
»^>s  deferred.     Death  ocrntLH       .^  ^^^"^'■'  ''^^  operation 
i'tun>or  was  founS  ISrifl'S'"'-^ i    ^^"^^-"orten" 
'"''e  of  the  thyroid  and  fo   ned  a   ,rl''''"'!,^'"'>'  '^^  '^^ 
"I'hes  m  circumference      hv^^'"""^  mass  eitrht 
;>'the  thyro-hyoiciVig^u  enf S:  bH '"^^^'  ^°  ^''^  '-^1 
l'e.side  the  trachea  to  the  b  f,  .! '  •        T  '^  P^^^^d  down 
■"ass  had  an  elongated  Lueww""'  ,^1°'"  '^^''i"''-  the 
end  rested  upon  the  Teft  b  on  h'     '   ^1 ''"''^•  '^'^  '°^^'- 
i  -neasured  one  and  three  uu^rf.?-     u'""^'  "'"s  surface 
I  "■  "PPe.-  right  angle  of  th'e  ma '    !"'?''  '"  '^"^''h.   At 
"ii'i  remnant  of  the  left  Inh^  T       •   "  f™"'  "^s  a  sniall 
?"es  of  the  two  blend  ni    not  f""^  ''^f  '"'""r-  'he  tis- 
■nKMightlobeofthethJfoidwafoT;''"^  ^'?' ■""  ''^^''^^'■ 

-s  a  rase'stm     :'to  Kret    11 '"•  ""T.  """  ^"^^^  '' 
f^'ioMtroma"t^:^S^^;::'-    ^'-growth 

don  n  the  trachea.  "   extensions 


'TIUORE. 


ficultic?  have  been 
i'lg  upon  the  situa- 
ave  been  described 
n  we  have  scarcely 

liug  all  tlie  forms 
gressiva— of  whicli 

?rtrop]iie   muscular 


which  atrophy  and 

irs  in  one  group  and 

recede.s  f'cr  months 

not  surprising  that 

Gowers,  however, 

ly  occur  in  families, 

lie  disease. 

ly  that  the  greatest 

g  forms  have  been 


e,  and  of  Landouzy 


■oth. 

plan  in  <lisregarding 

nder  the  designation 


It 


lished  by  Dr.  B.  Sachs.    .\ow  York  Med.  ,In„ri 


University  Hospital 


nal,  jJec,  10,  isaS, 


Jr  has  reoeutly  beau  pub- 


r    :i 

mi: 

Wj' 

J. 

:h 

g 
(. 


>                                        * 

I 

i  ?_ 

^ 

2 

'     1 

^£i^ 

ll 

Xd-lx 


Extract3d  from  tlio 
Amej-icar^JcHu^n^^  f,^^  September,  1880. 


ON  A   CASE   0I< 


HUMKRAL   MUSCLES. 
By  \Vii.liam  (Jslkk    M  I) 

HRorE8Hou  or  „k,„c,nk,  .un,s.  „o..k,ns  v.n,>.,n\,  n.tT,.,„„K, 


.J..H  ,•  '^''''''^•■■'\""";*  '"'""^"T  "'vopatlne.,  the  difficultios  have  been 
gieatl  noreased  by  the  .lesenption  of  tunas  depending  upon  the  situa- 
tion of  the  atrophy.  Varieties  of  tl>e  .une  disease  ha^;  iLn  d^c^d 
Z::X^  nuUad.s,  and  iron,  the  inevitable  contusion  .e  have  scarry 

Erb  has  sin.plified  matters  ve,y  nu.ch  by  gnn,,)ing  all  the  forms 
under  _o.e  des.gnation-dystrophia  muscuIari;pr4rc:siva-of  wS 
two  eluet  types  are  recognized: 

parah-r^''  ^"'"'''■'  ^''''''''''"^'^'> '  '^''   P-udo-hypertrophic   n.uscular 

(2)  With  primary  atrophv. 

As  cases  of  pseud^-hypert.-ophic  paralysis  occur  in  which  atrophv  and 
hypertrophy  exist  in  the  same  nu.scle,  or  wasting  occurs  in  one  group  and 
enhiyement  m  another,  or  atro,l,y  in  one  group  precedes  for  mont^' 

.e  development  of  hypertrophy  in  another,  it  is'not  surprising  th  i 
th  se  two  forms  are  regarded  by  .nany  as  identical.     Gowers,  however 
calls  attention  to  the  fact  that,  w!,en  cases  of  atrophv  occur  in  families 
they  never  present  the  features  of  pseudo-hvpertrophic  disease 

It  IS  m  the  cases  with  primary  muscular  atroi>hy  that  the  greatest 
confusion  exists  m  classification,  and  the  f.  .wing  forms  have  been 
recognized  and  described  :  "s  na^e  oeen 

(1)  Ei'b's  juvenile  form. 

^l^,^!"^  facio-scapulo-humeral  form  of  Duchenne,  and  of  Landouzy 
ana  Uejerine. 

(o)  The  hereditary  fe-m  of  Levden. 
(4)  The  peroneal  type  of  Charcot,  .Marie,  and  Tooth 
Gou-ers  ht,«  it  seems  to  me,  followed  the  sensible  plan  in  .lisregarding 
all  of  these  subdivisions,  and  describing  the  cases  under  the  designation 
simple  idiopathic  muscular  atrophy.'" 

GASE.-Sebastian  ]5.,  aged  fifteen,  sent  to  the  University  Hospital 
iisnea  by  Di.  B.  Sachs,     >ew  York  Me.;..  Journal,  Dec.  15.  1888. 


11 


i' 


I  i- 


K 


M 


2  OSLER,    IDIOPATHIC    MUSCULAR    ATROPHY. 

November,  1888.     Good  family  history,  both   parents  living;    mother 
lame,  cause  unknown.     Has  one   brother,  aged  twenty,  and  a  second 
aged    thirteen.     J  las   three   sisters,    aged   seventeen,  eight,   and    three 
respectively,  all  well.     Two  brothers  are  dead,  cause  unknown. 

rermwd  /ustori/.—Ha  has  had  measles,  smallpox,  and  |)ossibly  scarlet 
fever.  For  several  years  he  has  iiad  attacks  of  aljclominal  pain.  He 
has  also  had  (■arache.  Until  five  years  ago  lie  was  well  and  strong,  and 
j)layed  about  like  other  boys.  From  this  time  he  had  gradually  been 
getting  weak  in  the  arms,  and  for  between  three  and  four  years  lie  lias 
not  beenable  to  whistle.  All  of  this  time  he  has  been  in  fair  health,  but 
has  had  increasing  dilficulty  in  dressing  himself,  and  in  getting  froni  the 
recumbent  to  the  erect  posture. 

J'rcicnt  condifion. — Station  erect,  back  not  curved,  gait  normal. 

Face  smooth,  immobile,  and  expressionless— the  so-called  facics  myo- 
pathi(iue;  naso-labial  fold  absent;  lips  project,  but  the  prominence  is  in 

Fio.  I. 


Appeiii-aiiro  "(  Ihco. 

part  owing  to  the  teeth.  The  eyes  are  large,  no  exophthalmos;  move- 
ment of  the  eyeballs  normal.  On  attempting  to  close  the  eyes  the  pal- 
pebral slitremains  open  about  two  mm.  in  breadth.  ]\Iost  forcible  con- 
traction of  the  orbicular  muscles  fails  completely  to  cover  the  eyes.  (See 
Fig.  1.)  He  is  unable  to  frown  or  to  pucker  his  eyebrows.  The'for'ehead 
can  be  wrinkled.  He  has  fair  power  of  movement  of  lips,  and  he  can 
pucker  them  in  the  movements  to  whistle,  but  cannot  make  the  sound. 
AVhen  he  laughs  he  o|)ens  the  lips  vertically,  but  the  angles  of  the  mouth 
are  not  drawn  out.  The  zygomatics  do  not  appear  to  act.  The  dilators 
of  the  nose  move  slightly  on  deep  inspiration. 

Neck.  Thyroid  is  a  little  enlarged.  The  clavic;.lar  portiim  of  the 
sterno-cleido  muscle  is  w!i.^te<l,  Jie  upper  part  is  better  marked  than  at 
the  lower.      Ihe  scaleni  seem  well  developed. 

Thorax.  Long,  and  depressed  in  antero-lateral  regions.  The  pec- 
torals are  extremely  wasted,  scarcely  a  portion  of  the  muscle  can  be  felt. 


'HY. 

viiig ;  mother 
1111(1  a  second 
it,   and    three, 

lOWIl. 

ios.sil)ly  .scarlet 
iial  pain.  He 
id  .stroiij^,  and 
radiially  heen 
V  yeai's  he  has 
ur  healtli,  hut 
Iting  from  tlie 

lormal. 

'd  f'aeies  niyo- 

iminence  is  in 


OSLER,    IDIOPATHIC    Ml'SCULAR    ATROPHY. 


thnos ;  move- 
eyes  tlie  pal- 
foreihle  eon- 
he  eyes.  (See 
The  forehead 
,  and  he  can 
:e  the  sound, 
of  tlie  iiioutii 
The  dilators 

n-tion  of  the 
rked  than  at 

i.     The  pec- 
3  can  be  felt. 


and   stand  out   pronniientiv.     Trj 


The  scapuhe  are  winjred 


)\ver  portion. 


The  superior  fod  o     ;      •;  .i  I  '  , ''  wnsted   mi.s  loui 

not  look  so  thill  fn.  1    ,  I  i',1      Tl'        •  '•''    T'^'''^-     '^'''^'  "^■•••'<  ''"'^'^ 
are  much  waste.!      Th  '.     ,1'  '''"'"•""  '^'""  "'"'  '^''^^^  "'"•^^'l^'** 

rhoniboi,ls  were  invo^;<l"'TS'^;;p:   ^^^T  ""^"'"'  "^  '^"  ^l^ 
the  scapular  fo.s.  show  with  .liarill'meulU:"""'"'"^"  '^^  ^''"''  '^"^' 

I'll.,  i;. 


.Showing  iniiscuhir  atrophy. 

th7ll''^'^'Tl ''■'■''■""''"■'  '"'^^  ^'•'^tremely  wasted.  n,ntrastin-  stroncr|v  with 
the    eg.       lie  movements  are  considerablv  impaired.    'The  rifdit     ■ 


it 


;  '     I       r     •   ■ 


4  OSLER,    IDIOPATHIC    MUSCULAR    ATROPHY. 

portion  of  the  niUHole,  j„st  above  its  insertion,  which  stands  out  with 
groat  pronunon.-e.     The  i>i,.o,,s.  triceps,  an.l   hra.hiulis  anti    Vo     Im 
8U  es  are  nuu.h  wasted.     In  n.ukin.^  strong  (lexion  of  the  arm  the.    is 
a  8  igh   hcliyon  thehieeps.     At  the  outer  niargin  of  thenm.e    ,m  t    f  t  e 
right  burps  there  is  an  oval,  firm  portion.     I'n.portio  a   y  nJ  ^n Icie 

rrZ';"-''V"''^^.-     '^''-.  ^■-•-'■"'   ■"--..•es'at  the  ,,dddl     fi  "       d 

a  .pnirter    inches.      The  supinators    imve  lost    their   pro lence      Ti 

flexors  reman,  .n  conside,-able  bulk.     The.-e  is  a  fai,'volun  e    f  n.us.  le 
in  the  extensor  surface.  Pro..atio..  and  supinatio..  a.v  perfec "  e  1.    u 
are   hui;  ,.o  spec.al  wasting  of  the  thenar  or  hypo.tlH...are,nineso 
the  interosseus  spaces.     He  cannot  .nake  a  hit  satisfactorily  with  eith  . 
hand.     Moven.ents  of  the  H,.ge,-s  a,-e  slow  but  perfect.     Tli,"  a. ^et' 
X^uZ'     '""'^'  "'"■'^'   ""    ^'''"   P^.lma.^urfi,ccs   ami  "ni- [i'l 
Fig.  2  gives  a  fair  representation  of  the  .listribution  of  the  at.-ophv 
Lowrre.vlrc,n,t,es.     The  glutei  do  not  appear  wasted.     The  th l  1  s  at 
the  nnddlc  measure  eleven  and  a  half  inchc's.     The  regio..  of  tele 
nal  vast,  seem  .so,,.ewhat  wasted.     The  calves  ,neasu,-e"nine  a<  la    a  f 
inches      No  wasting  of  the  leg  muscles.     Moves  the  feet  and  toes  jleil 

jeiltlrS;  f^S"^  '""""•  '^""^'^•"  ^^^'•^"••'^'•^  I-'-^^-^-  ^-'- 
onie^a^;^^  ;;S'  '"^'  '""  ""^  ""  "'"•^'""  ^^'^^^^eneration  in  any 
The  patient  can  still  dress  himself,  but  with  difHcultv.  When  reci-m- 
bent,  he  cannot  raise  himself  upright.  He  gets  out  of  bed  bv  rol  ii  .  the 
feet  and  legs  out  first,  then  turning  on  his  fhce  and  .sli.ling  ,;ut.        " 

_    Duchenne  first  described  a  foi-.n  ot  muscular  atn.phv  beginniiur  i„ 
infancy  an.l  attacking  the  muscles  of  the  face.     Landouzv  ami  Dg- 
jerme  (lievue  de  MHecine,  1885)  have  studied  this  form  with  great  care 
and  regard  it  as  diHerent  from  the  other  forms  of  juvenile  hei-editarv 
myopathies.     In  their  first  communication  they  described  two  families 
and  reported  a  post-mortem  which  showed  the  spinal  cord  to  be  normal' 
In  a  second  communication  {Revue  de  MHecine,  December,  1886)  they 
described  six  cases,  and  again  ex])ressed  doubts  as  to  the  identity  -  ^  this 
w.th  Erb's  juvenile  form,  and  also  denied  that  it  has  any  connectio.. 
with    pseudo-hyperti-ophic   muscular    paralysis.       Marie    and    (Uiinon 
{Revue  de  Medecine,  1885)  describe  four  cases  in  two  families,  in  one 
instance  beginning  at  the  age  of  thirty.     They  Imld  that  this  fo,-m  i- 
not  essentially  diffe.'cnt  from   the  other  varieties  of  the  i)riinarv  nivo- 
pathies.     Kemak  {Xenrologlsches  Centmlblalf,  1884)  describes  the  case 
of  a  man,  age.l  thirty-two,  in  whom  the  affection  began  in  childhoo<l  • 
there  were  other  membc-s  of  the  familv  also  affected.     He,  too  seems 
to  regard  it  as  a  va.-iety  of  the  juvenile  form  of  progressive  muscular 
atrophy.     Kreske  {Neurologisches  Centralblatf ,  1886)  rep(,rts  the  ,.a«P  of 
a  boy  of  ten,  affected  since  his  fourth  year.     There  were  no  other  mem- 
bers of  the  family  affected.     Singer  {Zeitschrift  fur  Heilkuude,  Bd.  8- 
Neurologmhes  Centmlblatt,  1887)  rej)orts  the  case  of  a  man,  a-^ed  thirty- 


OPHY. 

stands  out  with 
uiiticiiH  on  l)()tli 
irin  tliero  i.s  still 
ppiT  part  of  the 
ly  more  niiiscio 
middle  five  and 
)!.iinonoe.  Tiie 
)liinu'  of  niiiscio 
feet.  The  hands 
eminences,  orot 
riiy  with  either 
There  are  little 
and    terminal 

the  iitro|)hy. 
The  tlii<,rhs  at 
)n  of  the  inter- 
ine  and  a  half 

and  toes  per- 

perfect.    Knee- 
leration  in  any 


1  reciMU- 


AVhei 
by  rolling  the 
r  out. 


OHI.KR,    IDIOl-.VTIIIC     MLSri-I, 


AH     aTKOI'IIY 


four. 


shoulder  and  of  the  f 


"'"'  '•"•  tw..  years  had  diffienlty  i.,  whist lin.r  •  tl 


!i''c  were  also  atilrted.      H 


as  only  a  variety,  not  a  s.-jmrat.'  alUvt 


le  muscles  .if  the 
>■',  also,  reirards  thi>'  tlu-m 


(I{rrup  dr    .]fnf,:rin>\  I.S.SS  ,   ,,||,| 


i"n.     Spillinaii   and   il 


iiiisli!iiter 


IM.Si) 


also  report  case 


^|)erliiig  .  Xnirnloi/!.->r/ir.i    (',-iit,ni/,/„ft 


Altoirether.   thei 


■e   ;ire    ii 


If  musculiii'  ati'd 


idiopathi 
has  heiriiii  inehildhond 
iH'^'an  at  the  forlietl 
atfeeted  the  face. 
two  years,  and  tl 


'■""''■''  '>'>(iut  lwentv-li\ f  (his 


I'l'.v-      111  theorcat  majority  of  case, 
"••"I  youth.    Oiu'caseof  Landou/vand  I) 


I   vcar  III  tl 


should 


variety  of 
he  disease 


'cjerine 


This,  uitii  the  caseofSJiiLier's,  wl 


le  case  of  M; 


er  and  arm  ;  fmr  years  ,'ater  it 
lii'h  heuiiii  at  lliirtv- 


years,  shows  that  the  onset  of  tl 


iM((  and   (iiiiuoii,  which   | 


life.     The 


alfect 


lo 


cases  a  I 


sec 


pathie  iniisciilar  iitrojihy,  and  J 
this  variety  as 


'"  to  conform  to  the  charact 


)ei^aii   at   thirty 
1"   may  he  delayed  until  a.iult 


eristics  of  simple  idio- 


Tl 


II  'Cpai'ate  disorder. 


see  no  rea.son   why  we  should  cl 


ISSI 


'y 


be 


le  eases  of  this  kind,  and  of  KrI. 


nearly  so  frecpient  in  th 


venile  form,  do  not  appear  t( 


which   is  not  at  all 


•^  ••ouiitry  as  the  pseudo-hypertrophic  variet 


the  case  of  James  Stewart 

no  ciises  of  Erh's  juvenile  for'iii  I 


ill!    uncommon    disease.      With   tl 


le  exception   of 


report  (Oniadn  Linrvt,  September,   I.S84) 


as 


I  I. 


lave   luH'u 


Icnow.  of  ilu.  so-called  Landou/.y.Dejerine  type 


reported,  and  none,  so  far 


y  t)eginning  in 
oiizy  and   D^- 
itli  great  care, 
lile  hereditary 
1  two  families, 
to  be  normal, 
er,  188G)  they 
lentity  '  "  this 
iiy  connection 
and    (niinoii 
iniilies,  in  one 
t  this  form  is 
)rimary  myo- 
ibes  the  case 
in  childhood ; 
ie,  too,  seems 
ive  muscular 
ts  the  case  of 
0  other  niem- 
■Mude,  Bd.  8 ; 
,  aged  thirty- 


!     I  M 


H         i 


p 

;■ 

ift   * 

1 

J              'i 

f  1' 

r 

im^t^t^^Bigmi 

t9^H^^H|^^^Hm 

E  („,  . 

jrjiill  1 

IliM 

fllilHP^  1 '. 

i 

.J|  1  ^   "'    '-'■;■[,    1    . 

L. 

r  1  ^ '  '1' '  ■ 

■ 

ll[l^^^_ml/ J' 

-Pr.„..  .0.  x„.  ,o„„..,  ..,  ,_,„  ,,..  ,,_,_  ,,,^^^^^^  ^^^^^^^_  ^^^^_ 


CASK   OF   SYPHILOMA    OF    TFfK   CORD   OF   TFfE 

CAUDA  EguiNA-DIOATH  FROM  DIFFL/SL: 

CENTRAL  MYKLrriS. 

Bv  WILLIAM  OSLER.  M    1) 

■•rof.s,or  of  Medicine,  John.  Hopkin,  U„iv«r,l,y.  Bal.imor.. 

THK  following  case  which  was  under  the  care  of  Dr  S 
Wc.r    ntchell.  at  the  Infirmary  for  Nervous  Dseascs' 

anato.^- ar;::^i^s. ''-'-''''  "^''">'  ^°'-^  ^^  ^'^"'-'  ^-i 

^V^/Vv./  5;.,/.;;M;:,^~.Chronic  alcholism.  history  of  syph- 
l.s.     For  n.ne  months  pains  in  the  legs,  particularly  in  the 

Changes.     I  ains  ,n  the  arms,  especialh-  the  right  •  no  w-ist 
ing  and   on  admission  arms  of  equal  Strength.     About  two 
months  before  death  loss  of  control  of  bladder  a  ul  r     t  ^ 
W.  hm  the  last  month  o,  life  loss  of  power  in  the  right    r^' 
Wjth  pa.ns ;  partial  loss  of  power  in  the  left  arm  with  maX' 
ed  mco-ord.nat.on.  complete  paralysis  of  the  left  leg    nl 
ual  loss  of  power  in  the  right.      Development  of  becl'  sCcs 
Ar thnt.s  m  knees  and  ankles.     Towards   the  close  of  life 
high  fever  with  delirium.  *^' 

ylna^o,u^h^/S.,.;,,rrJ.--Gumma  in  antero-lateral  columns 
of  erv.cal  cord  opposite  the  right  fourth  anterior  nerve 
root.  Gummata  mvolving  the  third,  fourth  and  fifth  ante- 
rior sacral  nerve  roots,  and  the  second  and  third  posterior 

Ztr'\  '"  ""'  'f  ^""     ^'^^^^"^-^^  degeneration   of 
he  left  posterior  median  column.     Central   myelitis.     Par- 
tial atrophy  of  the  sciatic  nerves. 

A.  B..  -.vt.  42,  lawyer,  admitted  February  5.  ,888.  Fam- 
ily history  good.  Had  been  a  hard  drinker  for  years  and 
h.o  .moked  ariu  chewed  to  excess.  He  had  gonorrhoea 
four  times  and  a  soft  chancre  but  no  history  of  second- 
aries  could  be  obtained. 


;  I 


M 


i 


:4! 


i*fi^ 


H        f 


2  n'lLLlAM  OSLER. 

In  1876  he  had  delirium  tremens. 

About  April,    1887,  he   began   to  have   sharp,   shootin" 
pains  in  the  arms  and  legs.     They  came  on  suddenly,  were 
stab-hke    in   character,   lasting  only  a    moment  and   then 
passing  ofif.     No  definite  regions  in  the  arms  and  legs  were 
mvolved.     He  also  had  dull  pains  in  the  back  of  the  head 
and  neck.     These  troubled  him  more  or  less  throughout  the 
,    summer,  but  he   could  get  about  fairly  well.     Towards   the 
second  week  in  October  the  pains  began  to  be  more  severe 
in  the  left  leg  ;  they  were  thought  to  be  rheumatic  in  char- 
acter.    About  the  twenty-fourth   of  October,  his  suffering 
was  so  great  that  he  was  confined  to  bed.     By  November 
5th  he   could  scarcely  walk.     The  pain  began   in  the  right 
arm  and  shoulder,  the  right  leg  also  was  painful  and  weak 
There  was  no  redness  or  swelling  of  the  knees,  but  the  left 
foot  and  ankle  would  get  red  and  swollen,  almost  purple 
The  left  leg  wasted  rapidly  and  for  a  time  he  lost  sensation 
m  the  legs  completely.     The  left  arm  remained  unaffected. 
About  a  month  before  his  admission  he  lost  control  of  his 
bowels  and  had  a  constant  desire  to  urinate.     He  had  to  use 
the  catheter  for  several  weeks. 

The  following  notes  of  his  condition  were  taken  on  ad- 
mission by  Dr.  Burr,  Resident  Physician. 

"  Pie  can  stand  a  little  with  the  aid  of  a  chair  and  he  can 
flex  and  extend  the  right  knee  and  hip.     He  cannot  move 
the  left  leg,  the   knee  of  which  is  swollen.     He   has   very 
little  pain,  none  in  the  right  leg.     The  wasting  of  the  left 
leg  is  marked.  The  knee-jerk  is  present  on  the  right  side  but 
on  the  left  side  it  is  obtained   with  difficulty.     On  the  right 
side  cremasteric  reflex  is  present,  absent  on  the  left.  Abdo-- 
mal  reflex  present  on  both  sic:es.    No  tender  spots  over  p   i   ,  ■ 
bed  sores  on  the  coccyx  and  on  the  left  buttock  ;  has   .  ain 
in   the  shin   bones  and    in  the   groin  at   night.     The  arms 
show  almo,st  equal   strength.     The  dynamometer  registers 
115  for  the  right  hand  and  120  for  the  left. 

For  two  weeks  he  seemed  to  be  in  much  the  same  state 
though  in  rather  less  pain.  Towards  the  end  of  the  month 
the  ankles  and  knees  became  more  swollen  ;  the  bed  sores 
had  healed. 


larp,  shooting 
uddcnly,  were 
cut  and  then 
md  legs  were 
k  of  the  head 
iroughout  the 
Towards  the 
;  more  severe 
natic  in  char- 

his   suffering 
3y  November 

in  the  right 
ful  and  weak. 
3,  but  the  left 
most  purple, 
ost  sensation 
d  unaffected. 
3ntrol  of  his 
ie  had  to  use 

aken  on  ad- 

■  and  he  can 
annot  move 
le  has  very 
S  of  the  left 
ightside  but 
")n  the  right 
?ft.  Abdot--- 
>  over  ?  1;  I  ; 
:  ;  has  ,  am 
The  arms 
er  registers 

same  state 

the  month 

e  bed  sores 


MARCH 


C^IS/-:  OP  SYPl/i/_oMA. 

On   March    i6th     Hi,.    „^^     •  ^ 

..nableto  move  t  "' ,-    ,  ,  T"   "  "'  '"°"°"'»  ^     ""•■-»   l--" 

"-  -veil,,,, ,.,.  t^^z  hie'";""  r''"^'  >-^^'-''^>'  ■' 

swollen  ;  the  finge,-,  oft  he  Ir  1       T^'''  ""■'  ^""^''•'  '''■'"•■""s 
yesterday  ;  p„i„\„„„7J    '■■■""'  —e  been  numb  since 

tl.e  pohus  o/  the  elbo  V  ^^l,  "'fr    ■"""  -">■'  -d  at 

'•ays;  ,-,ght  ha,.,  is  powefC    fi  ' '  rf  helT  '"  1"  =^^="' 


pressure  "  ''  """'"'  vertebne,  worse  on 

aiiy':rehi,;Tr;':„':r..r.':is"rtT''r""'^-  --  ^-""- 

"Inar  distribution  of  bo'l,  l,:'!'''^'^  "=  '"''  '--"-  '"  «- 
ealk','ati™°n';r:v''"'  "''"  '°  --'y  ™-ed,  when  ho  will 

lH,ll,xo'  thl"     .  '^    'on","';     ""^  '°^''"^  g-K-nous 
ing  to  10,°  in.l  r .,  ,  1     f  '  ''""I'"-'"""-'  --"se  this  ,norn- 

i.  reached  i^,^^ t  "^1,''  '"^"  .•^"  '"^^  '"-""«■     At  2  ,..  „. 
'"  ■02»  by  eVeninij  '''°"°'""    ""''  """"*"'"  ''"''""^  " 


Ml  J 


!        I 


4  n'll.IJAM  OSLER. 

22d.— The  delirium  persists  and  bed  sores  have  again 
appeared  ^on  the  sacrum  ;  the  scrotum  is  oedematous  ;  he 
has  difficulty  in  swallowing-  ;  the  breathing  is  diaplirag- 
matic  ;  does  not  complain  o  f  pain  ;  temperature,  to-day 
remained  below  104". 

23d. — General  condition  unchanged  ;  is  unconscious  and 
is  roused  with  difficulty  ;  morning  temperature  was  102" 
rising  gradually  during  the  afternoon  till  it  reached  105.6^ 
at  7  P.  M.  ;  at  lo  1'.  M.,  it  was  106.8" 

24th. — Low,  delirious  fever  continues,  reaching  at  12  M. 
107''  and  continued  elevated  during  the  afternoon.  At  10 
P.  M.,  the  rectal  temperature  was  108'^'  ;  at  12:30  A.  M., 
108.4^  ;  at  2  A.  M.,  108. S''  ;  at  3  A.  M.,  109.4",     See  chart. 

Death  occurred  at  4  A.  .\[.      , 

Post-mortem,  five  hours  after  death. 

Body  emaciated,  left  leg  smaller  than  the  right ;  scrotum 
oedematous ;  superficial  gangrenous  bull.e  on  each  heel ; 
recent  bed  sores  on    sacrum. 

The  skull  cap  was  removed  with  difficulty,  as  there  were 
strong  adhesions  to  dura. 

Logitudinal  sinus  contains  blood.  Parts  at  the  base  of 
skull  normal ;  cortical  arachnoid,  opaque.  Pachiionian 
granulations  abundant  and  large  ;  pia  mater  turbid,  strips 
off  readily  from  hemisphere,  but  is  somewhat  oedematous. 
Convolutions  look  healthy,  and  the  gray  matter  is  of  a  rosy 
pink  color ;  white  substance  moist,  with  very  few  bleeding 
points  ;  lateral  ventricles  look  dry  ;  third  and  fourth  ven- 
tricles present  no  changes  ;  in  the  latter,  the  vessels  just 
above  the  acoustic  stria;  are  a  little  congested. 

Section  of  the  ganglia  at  the  base  show  no  foci  of  dis- 
ease; pons  and  medulla  symmetrical;  no  descending  lesions. 

Cerebellum  normal. 

Spinal  Cord. — Dura  mater  natural  looking,  nowhere 
adherent  except  at  the  anterior  part  of  cervical  enlarge- 
ment;  no  sub-dural  exudation;  arachnoid  thin  and  clear. 
On  the  right  half  of  the  cervical  enlargement  the  dura  is 
attached  to  the  arachnoid  and  to  the  pia  over  an  area  the  size 
of  a  split  pea.  There  is  here  a  firm  solid  mass  in  the  cord, 
not  producing  any  special  deformity,  but  appearing  extern- 


;here  were 


.CASE  OF  SYPIHLOMA. 

ally  as  a  grayish  region,  situated  between  the  anterior 
roots  of  the  third,  fourth,  and  fifth  cervical  nerves  The 
fourth  IS  involved  in  the  adhesion  of  the  dura  The  ante- 
rior roots  are  not  involved,  nor  does  the  adhesion  of  the 
dura  extend  laterally  beneath  tiie  dentated  ligament  The 
grayish  translucent  appearance  of  the  mass  extends  for 
about  a  line  beyond  the  posterior  median  fissure  Ver- 
tically it  is  about  one-third  of  an  inch  in  length 

Fresh  sections  were  made  at  the  following  points  ■ 
Second   6.7-r7V.?/.-Interior   soft,    but    outlines   of    ..ray 
matter  distinct.     The   left  column   ofGoll   has   a  grayish- 
white  translucency. 

S,xth  Ca-vical.~Qr.xy  matter  has   lost  its   firm  appear- 
ance, and  is  very  soft  and  reddish  in  color. 

Seventh  6'r/-77W?/.-Central  softening  still  apparent.    Cor- 
nua  not  distinguishable. 

Second  Dorsal.— Qx^y  matter  more  natural  looking 

Eleventh  Dorsal.-OvxWm^  of  gray  matter  quite  distinct 
Ihere  is  a  marked  degeneration  of  the  left  postero-median 
fasciculus. 

The  Cauda  equina  presents  the  following  alterations  • 
The  three  last  anterior  nerve  roots  leaving  the  conus 
meduUans  are  involved  in  a  gummous  growth  the  size  of  a 
bean,  into  which  pass  also  the  posterior  roots  of  the  second 
and  third  sacral  nerves  of  the  left  side.  They  are  involved 
about  two  inches  from  the  cord.  Lower  in  the  canal  there 
are  two  or  three  small  fibres,  which  present  slight  tuberous 
enlargements. 

The  tumor  of  the  cord  varies  in  transverse  diameter 
from  three-eighths  to  one-quarter  of  an  inch  in  diameter; 
it  is  completely  within  the  cord,  the  symmetry  of  which  is 
not  materially  altered  (Fig.  i).  In  shape,  above  and 
below,  It  IS  rounded  ;  in  the  middle,  more  ovoid.  The  ver- 
tical extent  is  not  quite  half  an  inch.  At  a  limited  region 
the  dura  is  adherent  to  the  pia,  which  membrane,  at  this 
point,  is  distinctly  thickened.     With  a  low  power  it  is  seen 


that  the  growth   occupies   the  right  antero-lateral 


destroying  and  pushing  aside  the  anterio  „..,^ 

the  antero-median  fissure  and  pushing  back  the  posterio^ 


region, 
r  cornu,  displacing 


t  i  . 


* 
1 

1 

;     i 

i  i 

•    i      i 

.J         ■  5 . 


Ui     :1 


I 


f  I  i 


6  WILLIAM  OSLER. 

cornu.  In  the  upper  part  of  the  growth,  the  outlines  of  the 
gray  matter  of  the  left  side  and  of  the  right  posterior  horn 
are  well  seen.  In  the  middle  portion  they  are  much  less 
distinct ;  and  here  the  growth  reaches  so  far  over  that  it  is 
only  one-eighth  of  an  inch  from  the  left  lateral  margin  of 
the  cord.  The  growth  is  firm,  not  encapsulated,  and  sec- 
tions in  ca.  mine  stain  of  a  deep  red  color.  The  greater 
portion  of  the  mass  is  made  up  of  a  dense  fibro-caseous 
tissue,  devoid  of  cell-elements,  and  through  which  passes  a 


''"'S-  I- — Gumma  of  cervical  cord  opjiosite  fourth  nerve  root. 

number  of  blood-vessels,  some  of  which  are  obliterated 
some  free.  At  the  periphery,  there  is  marked  cell  prolifer- 
ation, particularly  towards  the  gray  matter.  This  is  also 
very  distinct  in  the  anterior  median  fissure.  The  anterior 
spinal  artery  is  involved  at  the  edge  of  the  growth,  and  the 
adventitia  encircled  in  three-fourths  of  its  extent.  The 
intima  id  greatly  thickened,  and  the  cell  elements  look 
much  swollen.  In  the  adherent  dura,  which  is  not  thick- 
ened, there  are  amyloid  bodies.  The  gray  matter  looks 
swollen  ;  at  the  upper  portion  of  the  tumor  area,  the  large 
cells  are  distinct,  but  the  nuclei  do  not  stain  well  in  car- 
mine.    In  the  middle  and  lower  portions  of  the  affected 


lines  of  the 
terior  horn 
much  less 
r  that  it  is 
margin  of 
,  and  sec- 
lie  greater 
ro-caseous 
h  passes  a 


Dot. 

)literated, 
1  prolifer- 
is  is  also 
;  anterior 
1,  and  the 
nt.  The 
:nts  look 
ot  thick- 
ter  looks 
the  large 
ill  in  car- 
;  affected 


CAS/-:  OF  sypiifi.oMA. 
neighborhood  of  ,,rves  *,"''■  P"""''"'*'  '■■   "- 

in  t'he't™;; ;:  t;';:";;  ""  ""=  ^'•'■""^'■^  "^^^-'^-^  ='•••- 

veryi„di:.™r;„t;;',ef'  ""'™^"''''  '"<"" -™"-.  and  ha. 

The  cervical  cord   nhnv,.  fU^ 
carmine  and  by  Wi  g  ,t  ,e     od^"  tT*''  ■''""  "'"  "  '^^'^ 
tinct,  and    the   nerve   r.I     7    ,  ^'''^'  '^''""''  '"^  ^''■^- 

nuclei  stain  well  °°'  '^'^'^^'^''^^  ^^^'^"-^  =  ^hcir 


Fig.  ..-Lumba,  cord,  .l,„wi„,  .■,,.„e„,i„„  .,  ,i.  ,,„  p„,^^,___.  ^__,^^^ 
The  tumor  of  tlie   Cauda   has  rr>-itto,i  n 

:r ':7  irdV="T".'  -■  "--^^"""-  *,■;:;::  ,r;: 

aieasot  indifferent  tissue  stained  red   snrrr.„n^    i  u 

of  actively  poliferating  connective    it utretn^^  n^  T^ 

stain   deeply  in   the  hematoxylin,     i:   Ih   Ven    J  c! t' 

seerL^r/'^  outlines  of  the   nerve  bundles  0";; 
seen,  and,    n  places,  numerous  irregular  areas,  lighter  in 
color,  closely  set  together,  which   represent  the   degcne 
ating  nerve  fibre   with  their  medullary  sheaths   nalo  Tn  i 
many  of  the  axis  cylinders  stained  ^      '  ''"^ 

esting.  In  the  lumbar  cord  ,t  involves  a  wide  area,  chiefly 
m  the  root  zone,  not  reaching  the  median  surface  or  the 
posterior,  except  close  to  the  nerve  root  (Fig  2)  In  the 
dorsal  cord  rFiV.  7^  fl,o  .^ot  7nn^  ;c  „   .  ■        ,      , 

-lot  zone  IS  not  involved,  and  the 

affected  except  a  narrow  wedge. 


w 


8 


fl 


'    r. 


I 


mm 


'1  I 


IVn.l.lAM  OSI.ER. 


In  the  region  of  the  tumor  the  degeneration  does  not  reach 
so  close  to  the  posterior  margin  (Fig.  i). 


A<a 


Fifr  3.  — Dorsal  cord.     Descending  degeneration  of  left  columns  of  Goll. 

i;|  The  left  sciatic  is  extensively  degenerated.    In  the  right 

there  arc  two  or  three  bundles  in  which  atrophy  is  appar- 
ent. By  Weigert's  method  the  contrast  is  very  striking,  as 
shown  in  Figs.  4  and  5. 


Fig.  4.— Left  sciatic  nerve.     CroEs  section. 

The  early  pains,  at  first  in  the  arms  and  legs,  then 
chiefly  in  the  right  arm  ;  the  wasting,  weakness,  and  grad- 
ally  total  paralysis  of  the  left  leg;  the  slow  onset  of  the 
paralysis  of  the  right  arm  with  paresis  of  the  left,  find  their 
explanation  in  the  progressive  growth  of  the  tumor  in  the 
cervical  cord.  The  involvement  of  the  anterior  sacral  roots 
was  responsible   in   part  for  the  loss  of  power  in  the  le"-s, 


ii     i 


f./.vA  (;/•■  \y /'////.().]/. I. 

but  the  early  afifection  of  the   left  with   rapid  wasting  was 
undoubtedly  the  result  of  the   cord   lesion  ^ 

The  accurate  localization  of  the  lesions  in  the  caudaec,uina 
makes  a  consideration  of  the  symotoms  produced  by  them  of 
sXnTn'tr'"^"^^'    ^;"^--^""'''^^l>'-  therelnonote.;!  ?en 

-r::::.;^  '^^\  ^j^-^  ---•  ^^  ^he  bladder 
«-in,  the  View  tS'r::;;^::Lr;:t:^ 


Fig.  s—Portion  of  cross  section  of  riyht  fciatic  nerve. 

sacral,  not  in  the  lumbar  segments  of  the  cord.  The  dis-* 
urbance  in  the  reflex  arc  was  here  chiefly  in  the  efferent 
branches  mvolved  in  the  third,  fourth  and  fifth  cords  It 
will  be  remembered  that  of  the  afferent  branches  only  the 
second  and  third  sacral  roots  were  involved 

A  third  point  of  interest  is  the  ascending  degeneration 
:n  the  left  column  of  Goll  due  to  ^he  lesion  ^in  the  ^^o  k 
edit  "  P;^^--'- ---1  -ots,  and,  in  part  also,  undoubt- 
edly, to  extensive  disease  of  the  left  sciatic  nerve  As  is 
shown  in  the  figures,  the  distribution  of  the  sclerosis  pre- 
sented the  well-known  variations  in  passing  from  the 
lumbar  to  the  cervical  cord. 


Lastly,  the  case  offe 


rs 


chief  symptoms  of  acute  cental  myeliti 


an   excellent  illustration  of  the 


high  temperature,  the  arthritic  disturb 


trophic  changes,  as  shown  i 


myelitis,  particularly  in  the 
inces  and  the  marked 


sores. 


n  the  rapid  development  of  bed 


li: 


[From  rnt  Jehu,  Mopkin,  Uo^pim  JJulleUn.  No.  1,  December,  1889.] 


ON  THE  VALUE  OF  LAVERAN'S  ORGANISMS 
IN  THE  DIAGNOSIS  OF  MALARIA. 

By  PROFES.SOR  William  Os^lkr,  M.  D. 


C-l 


The  attitude  of  the  profession  on  the  ,,ueHtion  of  nucro-orKanisn.«  of 
malam  ih  o,,e  of  judicions  nkeptici.sn,.      Between  the   badZ  nXii 
of  Klebs  and  Toma.ssi-Crudelli,  and  the  protozoa  described  by  l!    e^n 
the  average  doctor  cannot  be  expected  to  decide;  but  even  a.nong  workers 
and  teachers,  there  is  by  no  .nean.s  unanimity.    So  far  as  I  Zw   there 
has  been  no  conHrniation  of  the  observations  of  the  first  nanuni  ."  U.'or     ,! 
a  speeifie  bacillus  in  the  disease.     It  is  far  otherwise  with  t  e  o  '  ^s^ 
described  by  Laveran,  whose  work  has  now  been  confirn.ed  In  2    ete" 
observers  in  Italy  America  and  India.     I  do  not  know  of  a  sinl  d     c  hn 
or  pathologist,  living  in  a  suitable  region,  who  has  really  2ke  he 

«ubjec  ,  who  has  not  been  convinced  of  the  truth  of  Laveran'.  tlmems 
Ooubtle^  many  have  had  ,ny  experience.  In  1886,  at  the  .„ee  g"  the 
sut  ;:.T'  T;  ''"""•'"  l^Hy-'ians,-  whe„  Dr.  Councilman  prelte  " 
summa.  of  Laveran's  views,  I  (speaking  out  of  the  fulne.ss  of  mv  ignorance) 
was  extremely  skeptical.     When   I   ha.i  the  opportunity  of  g  vin-    to  the 

'nd r,:;  th^  r;';-' 'z-^^-^-^'^^^-^^^^^h i wLso^ic:;;^^^ 

.md  I  h ad  the  satisfaction  of  confirniing,  in  almost  everv  particular  the 
observations  which  Laveran  had  made,  and  discussed  the  whole  uW  t'in  a 
paper,  published  in  the  British  Medkal  Jo^^rnal,  March  12,  1887  For  the 
past  two  years,  at  the  Philadelphia  and  University  Hospitals,  I  have  id 
abundant  opportunities  of  studying  cases  of  malaria,  witli  !n  ever-deenening 
conviction  that  the  organisms  of  Laveran  are  peculiar  to  tlie  disease.'         ' 

L^^l%  ^''''  ""'  "^  '^l  '"'^'  distinguished  pathologists  in  India, 

repeUed  by  the  apparently  extraordinary  statements  of  Laveran,  and  had 

the  J  T/Ti  Tf^  '"  ''"'  '"''J'''*'  ""*"  ''"^  appearance  of  my  paper  in 

,?!k          .  "''''''•     ^''  ''''^"™*«  contribution  to  the  subject,  one 

illir  TT.'^^'l '''"'''' '"''  ^''"  '""'^^'  ^°"fi"-'»«  i"  ''•"'^^t  every  detail 
the  statements  of  the  French  observer.  To  the  impartial  student,  this  remark- 
able unanimity  in  observations  made  by  Laveran  in  Algiers,  by  Marchia- 
faya  and  Celli  and  Golgi  in  Italy,  by  Councilman,  James  and  myself  in 
this  country,  and  by  Vandyke  Carter  in  India,  should,  to  say  the  least 
carry  conviction  as  to  the  importance  and  con.stanev  «f  these  bodies  in 
uiaiana.    While  it  may  be  a  little  early  to  ask  acceptance  of  the  view  that 


M 


:  b 


i| 

i 

lllfl 

i    i 

>  MM 

'1H 

1  - 

.1  ^H 

i 

^^H 

;   ■ 

. 

^-'^^1 

. 

these  orsiininmn  constitute  the  speiiCic  germ  of  the  diseMNe,  the  work  iilreiidy 
(lone  warrants  positively  the  statement  that  they  are  peruliar  to  ami  diag- 
nostic of  the  presence  of  the  malarial  poison.  It  i^  not  surpriwing  that 
certain  ohservcrs,  who  have  perhaps  seen  hut  few  case.-.,  have  Ix-cn  inclined 
to  regard  the  >  hanircs  in  the  red  corpuscles  its  dei,enenttivi"  rather  than  as 
the  manifestations  of  an  intracellular  parasit"  ;  hut  the  study  of  the  reniar'.c- 
ahle  serial  development  of  the  sci^mcnting  fonm  descrilied  hy  (iolgi  cannot 
possibly  he  explained  hy  any  other  view,  than  'hat  we  i<re  dealini;  here 
■with  an  independent  organism.  The  cresccntic  l.i«lies,  too,  are  so  peculiar, 
so  eharacloristic,  so  unlike  anything  which  we  M)eet  with  in  tlie  hlood  in 
other  conditioiiH,  that  1  have  usually  found  it  an  easy  niacter  to  convert  the 
most  hardened  unheliever  hy  a  deuKtustratinn  of  their  presence  in  a  few 
eases.     Still  more  remarkah'e  are  the  llagellate  organisms. 

Putting  aside,  for  the  time,  until  the  complete  life  history  of  these  organ- 
isms shall  he  worked  out,  the  (piestion  of  their  .■tiol()gi(!al  relat'on  to  the 
disease,  1  woulil  liriedy  refer  to  their  tliagnostic  importance.     In  my  former 
paper,  I  gave  in  this  connection  several  interesting  illustrations.     Since  tliat 
date,  1  have,  in  an  increased  experience,  become  even  more  convinced  of  the 
really  great  value  in  donhtful  ciises  of  these  hlood  e.xaniinations.     In  ordi- 
nary intermittent  fever,  of  recent  origin,  there  is  hardly  (  ver  any  ques- 
tion in  the  diagnosis,  and  any  douhts  H'hich  may  c.\ist,  quinine  re.adil) 
clears   u|>.     The    value   of   the    hlood    examination    lies    particularly   in 
the  ciironii'  cases  and  in  anomalous  forms.     Here  oui^  has  to  he  constantly 
on  guard  and  it  may  he  impossihle  for  days  to  determine  definitely  the 
nature  of  the  aftection.    We  have  since  the  opening  of  the  hospital,  ad- 
mitted twenty-four  cases  of  malaria   to   the  ward.s,   of  which,  i..   seven 
instances,   the   diagnosis   was   definitely   determined    hy   hlood   examina- 
tion, and  I'ould  have  hecn  determined  in  no  other  manner.     So  important 
do  we  consider  it,  that  '..e  now,  as  a  matter  of  routine,  examine  the  hlood  of 
all  cases  of  fever,  and  indeed  all  cases  of  low  temperature,  which  seem  so 
peculiar  in  certain  forms  of  chronic  malarial  poison.     We  had  a  salutary 
lesson  in  the  early  part  of  the  s'-  Miier,  in  the  case  of  an  old  man,  aged  81, 
admitted  July  2oth,  with  a  temperature  of  104°.     He  had  on  the  9th,  a 
heat  stroke,  while  picking  berries,  was  better  the  next  day  and  kept  about 
until  his  admission.     There  were  signs  of  bronchitis  at  the  bases  of  the 
lungs,  and  in  the  right  inter-scajmlar  region,  the  note  was  higher  pitched 
and  the  breathing  tubular.     The  temperature  rose  to  10')°,  and  throughout 
the  2Gt!i,  27th  and  28th,  kept  between  101°  and  103°;  on  the  28111,  between 
the  hours  of  tj  and  12  a.  m  ,  the  temperature  was  subnormal,  hut  he  hiid  no 
chills.     He  was  extremely  feeble,  not  cachectic  or  sallow ;  the  pulse  was 
very  irregular.     Neither  I  nor  Dr.  Atkinson,  who  saw  the  case  for  me  dur- 
ing an  absence  of  three  ^.ays,  had  any  other  idea  than  that  the  case  was  one 
of  low  pneumonia  in  an  elderly  man.     The  patient  died  on  the  Sth  day  of 
his  ailmission,  and  to  my  surprise  and  chagrin  the  post-mortem  examina- 
tion of  the  blood  and  spleen  showed  the  case  to  have  been  one  of  malarial 
fever.     Had  a  thorough  blood  examination  been  made  and  full  doses  of 
quinine  administered,  the  man's  life  might  have  been  .saved.     In  five  or 
six  cases  of  irregular  fever,  the  presence  of  the  organisms  in  the  blood  has 
determined  the  nature  of  the  disease. 


le  work  Jilready 
iiir  to  iiivl  liiag- 
Hiir()ri»in>;  that 

0  Ix't'ii  incliiit'd 
riilhi'i-  than  as 

'  of  the  reinarlt- 
ly  Ool^i  camiol 
e  (lealiii^  licre 
art'  so  ]i('ciiliar, 
ill  tlu'  hh)od  ill 
•  to  convert  th« 
'senci'  ill  a  few 

of  these  orijan- 
rclnt:i)n  to  tlie 
111  my  foriiior 
nw.  Since  that 
invincetl  of  the 
ions.  In  onli- 
vcr  any  (]ues- 
uiniiie  readily 
jarticiilarly   in 

1  i)e  constantly 
definitely  the 

f  hosnital,  ad- 
licli,  1..  seven 
lood   exaaiiiiM- 

Ho  important 
lie  the  blood  of 
which  seem  so 
had  a  salutary 

man,  aged  81, 

on  the  9tli,  a 
iiid  kept  about 
e  bases  of  the 
iiigher  pitched 
nd  throughout 
■  28tli,  between 
but  he  had  no 
the  pulse  was 
ise  for  me  dur- 
e  case  was  one 
the  Sth  day  of 
rtein  examina- 
ne  of  malarial 
\  full  doses  of 
id.     In  five  or 

the  blood  has 


The  routine  exu.iunution  is  really  not  tedious,  and  we  have  adopte.l  it  now 
n  the  dispensary,  as  well  as  in  the  wards.     Unfortunately  for  the  general 

.ratu.oner,tlie  determination  of  the  intra-celhilar  forms  re.,uireH  a  tolerabl. 
high  power  with  gcKxl  illumination.  We  use  the  one-twelfth  immersion, 
but  wuh  care  a  goo.l  eighth  is  sullicient,  an,l  in  the  chroni.'  cases,  with  the 
crescents  u,  the  blood,  a  sixth  su.Hccs.  1,  is  important  to  have  the  finger 
Up,  from  which  the  blood  is  drawn,  thoroughly  cleansed,  and  it  is  best  to 
take  |.  very  small  drop  of  bUn..!,  so  as  to  have  the  laver  uniformlv  and 
thinly  spremi  out  with  the  corpuscles  isolated  not  in  rouleaux 

Hr.efly  to  sum.i.ari/c  for  the  information  of  those  who  may  not  have 
access  to  monographs  on  the  subjc,,,  the  following  are  the  im,,;.rtant  facts 
relating  to  these  organisms: 

First;  In  the  acute  forms  of  malaria  there  exists,  within  certain  of  the 
red  corpusc  es,  amoeboid  bo.lics,  usually  pigmeiite.l,  which  iin.lergo  « 
definite  evolution,  increasing  h,  si.e,  gradually  filling  the  entire  corpuscles 
aud  which  prior  to  and  .luring  the  chill,  undergo  a  remarkable  segmeii- 
tatioii.  I  here  are  also,  in  some  cases,  free  i.igmented  bo.lies.  To  the  form 
within  the  corpuM'les,  which  undergoes  ciianges,  the  term  plammdium  has 
beenai.p  ie,l  Occasionally  in  acute  forms,  flagellate  bodies  arc  seen  free 
in  the  bloo.l,  presenting  from  three  to  eight  long,  actively  moving  cilia. 
According  to  Councilman,  these  are  much  more  common  in  blood  with- 
drawn from  the  spleen. 

Second;  In  more  chronic  cases,  particularly  in  the  forms  of  remittent 
fever,  which  .are  .so  apt  to  be  taken  for  typhoid,  the  corpuscles  .lo  not  so 
often  j.resent  the  intercellular  forms,  but  there  .-..-e  remarkableovoid,  rounded 
and  crescentic  bodies  deeply  i,igmeiited.  These  are,  in  all  probability,  related 
to  and  developed  from  intercellular  forms.  From  certain  of  tbe.se,  particu- 
larly the  ovoid  and  rounded  forms,  the  flagellate  bodies  mav  be  seen  to 
develop.  Dr.  (Jhriskey  has  recently  been  studying  the  evolution  of  these 
forjis  in  the  Clinical  Laboratory,  and  has  been  able  to  demonstrate  on 
many  occasions  the  development  of  the  flagellate  bodies  from  ovoid-rounded 
forms. 

I  hope,  in  an  early  number  of  the  forthcoming  Hosjiital  J^eports  to 
review  fully  the  present  status  of  the  malaria  .[iiestion  and  to  report  our 
exiierience,  i)articularly  in  the  anomalous  forms  of  fever  in  which  the 
blood  examination  is  .so  important.  It  is  i)articularly  t„  be  desired  that 
those  who  have  ample  opportunities  for  the  study,  "shall  approach  the 
problem  with  unbiassed  minds.  It  rciuiivs  a  little  patience  in  or.ler  to  be- 
come thoroughly  familiar  with  the  various  phases  of  <levelopmcnt  of  the 
organisiii.  Additional  workers  are  needed.  We  have  yet  to  determine  fully 
the  relation  of  the  forms  to  each  other  and  the  complete  life  historv  of  the 
parasite  in  the  body ;  and,  what  is  much  more  important,  to  ascertain  its 
existence  outside  and  to  learn  the  conditions  of  its  development  and  the 
way  in  which  it  gains  access  to  the  body. 

A  ready  method  of  separating  malarial  from  other  forms  of  fever  will 
prove  a  great  boon  to  southern  physicians.  Dr.  Carter's  paper  contains 
many  illustrations  of  the  value  of  Laveran's  observations  in  this  respect, 
and  workers  in  sub-tropical  and  tropical  regions  cannct  longer  afford  to 
neglect  so  valuable  aa  aid  in  dia-ruusis. 


1 

s 

1: 

■I 


en 


W  Tw  .   *     r        ^^  ^'^    ASSOCIATED 
By   WILLIAM   OSLEP    M.  D. 

passages  by  .alculf,  .„„,„,.  ,.i,.        "         "'"  "''^"■""" '■"'<•  ''"" 

I02»     In  a  ,.on,n,.L    :     a    L    ll!  i     f  ".'I'''""",'"  '■'■* "'"« 
with  .lilliiso  „„„..,■  ,l„.„™*   ,         ■       ■    °  "'"I"'"'' or  rinhmh 

In  the  large  .„  Jl„  rt,  1 ' '  '  ""'*'l™"">-  '™»i"''l  normal, 
when  co,„ti„ed  »  t  u,n  e  tn  I  f''*"''"'  "  "''*""  "''  '""" 
Mate  betw.,,  tiu»  .■S^  ^a  ^jf  Z:^'^''' '°  """■'•'- 
liver.  I  have  „„,,.  „„..  «„  „  ,„  ™  ^  i  i  ;  t; '  r'«'-»'  o''  «>» 
risors,  i„  a  ca«o  „f  oa,,.,,.  „f  the  liver  ™,     1,  '"'''' ^^'^ 

«oo„dary  «.„e.,'thero  were  ne^^U  ^U  .tl  :[  "  T'"'"" 
pression  of  larirer  gall  -inets  hv  Ihe  tm„  ,      ' ,  ^         """ 

«.-.or,„„fi„.e.™i..e„tp,4i:ti;;:i:.i— ^^^^^^^^^^^^ 

1 


1(f 


•i 


1 


i 


t' 


:) 


1 


I  1 


growing  cancer  of  tliis  organ,  such  as  Hampeln'  has  described  in  cases 
of  cancer  of  the  stomach  and  such  as  are  met  with  oc-casionally  m 
rai)idly  growing  lympliatic  growths,  as  noted  by  Pel  of  Amsterdam. 

Since  writing  tliis  paragraph,  tlicre  has  been  in  tlic  Hospital  a 
ease  of  primary  cancer  of  tlie  left  lobe  of  the  liver  in  a  young  man, 
who  gave  a  history  of  several  rigors  of  so  pronounced  a  nature,  that 
among  other  pt)ssibilities  that  of  abscess  was  discussed. 

C7/r/(o.s/.s.— It  is  not  usually  recogui/ed  that  in  cirrhosis  there  may  be 
fever.  The  systematic  authors  on  atfcctions  of  the  liver,  sucli  as  Fre- 
richs  :md  :Mur(;liison,  speak  of  sliglit  pyrexia  in  the  early  stages,  par- 
ticulailv  when  the  organ  is  enlarged.  Carrington ''  has  made  an  inter- 
esting studv  of  this  question,  and  states  that  of  forty-four  cases  in  which 
temperature  observations  were  made,  in  thirteen  fever  was  a  more 
or  less  marked  svmi)tom.  In  (pertain  cases,  sucii  for  example  as  the 
one  which  he  described  in  full,  serious  diilicultics  in  diagnosis  might 
readilv  arise  and  it  would  be  cpiite  pardonable  to  suspect,  from  the 
irrcgu'laritv  of  the  temperature  curve  and  the  existence  of  slight 
jaundice,  that  suppuration  was  going  on.  .My  experience  with  fever 
in  cirrhosis  is  small  and  I  have  n..t  my  clinical  records  at  hand  to 
examine  into  the  pcjint.  1  have  a  ilistin(^t  recollection  in  one  or  two 
instances,  particularly  in  the  hypertrophic  form,  of  marked  increase 
in  the  temperature,  but,  I  should  say  that  in  the  majority  of  instances 
of  cirrhosis,  fever  was  not  a  special  symptom. 

Ohstradioii  of  the  Duct  bij  GalMonc^.—Sim'e  the  bile  passages  have 
been  brought  within  the  s])hei-e  of  surgery,  a  renewed  interest  has 
been  taken  in  all  symi)t(.ms  which  give  us  more  accurate  knowledge 
of  the  character  and  situation  of  lesions  in  these  parts  ;  and  I  wish 
particularly  in  this  paper  to  deal  with  a  form  of  fever  met  with 
ehielly  in  chronit;  obstruction  of  the  common  duct  by  gallstones,  as  it 
possesses  features  of  the  greatest  importance'  for  diagnostic  purposes. 
The  fever  I  si)eak  of  is  intermittent  in  character  and  the  cases  pre- 
sent the  following  group  of  symptoms  :— 

First :  Jaundicie  of  varying  intensity,  deepening  after  each  paroxysm, 
and  whicli  may  persist  for  months  or  even  for  years. 

Second  :  Ague-like  paroxysms  characterized  by  chill,  fever  and 
sweating,  after  which,  the  jaundice  usually  becomes  more  intense. 

iZeitschvift  f.  kliii.  Moiiicin,  Bil.  XIV. 
2  Guy's  Hospital  Keports,  1884. 


»ed  in  cases 
iionally  in 
jtei'dam. 
Hospital  a 
oung  man, 
ature,  that 

uM'o  may  be 
icli  as  Fre- 
jtagca,  par- 
ie  an  intor- 
es  in  which 
,as  a  more 
nj)lc  as  the 
losis  might 
t,  from  the 
[>  of  slight 
with  fever 
at  hand  to 
one  or  two 
ed  increase 
of  instances 

ssages  have 
interest  has 
knowledge 
and  I  wish 
L'  met  with 
stones,  as  it 
c  purposes. 
i  cases  pre- 

1  paroxysm, 

,  fever  and 
intense. 


Third  :  At  the  ti 


me  of  the  paroxysms,  pains  in  tl 


le  region  of  the 


/  liver,  with  gastric  disturbance. 

In  a  majority  of  cases  tliis  combination  of  svmptoms  is,  I  believe 
characteristic  of  the  exist.-nce  of  gallstones  in  ihc  common  duct.         ' 

We  meet  with  rigors,  fever  and  sweats  in  three  conditi.ms  of  the 
biJe  passages : — 

_  As  an  acute  and  transit...-y  proces.     >  ordinarv  hepatic  colic  asso- 
ciated with  the  passage  of  a  stone  through  the  d'nct. 

In  chronic  ..l)stniction  of  the  duct,  us.ially  by  st<.ne,  without  lesions 
of  the  bile  passages  otlu^r  thai,  dilatation  and  catarrhal  cholauoitis 
In  suppurative  cholangitis  produced  by  gallstones  or  other'i-auses. 
W  ith  the  first  of  these,  1  an.  not  speciallv  concerned,  ex<-ept  so  far 
as  It  may  help  to  explain  the  occurrence  of  the  j.aroxvsms  in  the  second 
group.  The  d.stin.-tiun  Ix^tween  the  <.ases  of  suppurative  cholangitis 
and  those  of  the  second  cafgory  shall  be  ..onsidered  subscjuentlv,  and 
1  sliall  lu.w  proceed  to  speak  of  intermittent  hepatic  fever  with  its 
associated  symptoms  as  characteristic  of  ehronic  obstruction  of  the 
duct  by  gallstones  and  without  suppuration. 

The  literature  of  the  subject,  though  interesting,  need  not,  for  the 
purposes  of  this  paper,  be  disc-ussed  at  length.  Of  the  numerous 
writers  on  gallstones  during  the  last  centiirv,  Soemmering'  appears  to 
be  the  only  one  to  mention  ^he  symptom,  using  the  phrase,  in  siicakincr 
of  the  fever  associated  with  gallstones,  "et  ipsa  febris  intermittens." 
\\  e  owe  to  French  physicians  our  knowledo-e  of  this  valuable 
symptom.  .Monncret^  is  usually  credited  with  it.-  recognition,  but  the 
thesis  of  INIagnin^^  and  the  \\<,rk  of  Charcot '  present  us  with  the  first 
satisfiictory  studies,  from  which  indeed  has  been  derived  mo^t  of  the 
information  on  the  subject  which  we  find  scattered  through  the  text- 
books  and  monographs. 

Among  (German  writers  the  work  of  Frerichs  contains  many  cases 
illustrating  this  symptom  of  chronic  obstruction,  but  he  does  not 
appear  to  lay  special  stress  u])on  its  importance  in  diairuosis.  In  von 
Schueppers  article  upon  gallstones,  in  Ziemssen's  Cvcloptedia,'  the 
remarks  are  leased  on  the  work  of  the  French  writers.'  Warner"  has 
reported  interesting  cases.     References  to  these  svmptoms ''occur  in 


*Du  Concrenientis  billariifs,  1795. 
'Paris,  1809. 
'  Vol.  IX. 


^  i'atliologie  Interne,  Tome  i. 
♦Lemons  siir  les  Maladies  du  Foje,  1877. 
'Deutsches  Arcliiv.  f.  klin.  Med.,  Ijd.  xxxiv. 


fV 


^ 


'i 

r 

'  i' 

J; 

■1 

s 

1    . 

i 

1  .. 

?■ 

i 

r 

«i 

« 

iliii  illi 


the  various  German  text-books,  but  the  question  does  not  appear  to 
have  received  the  full  consideration  which  its  importance  demands, 
and  the  majority  of  the  writers,  as  Striuiipell,  for  example,  speak  of 
the  fievre  intennittcnte  hcpatique  as  if  it  were  always  associated  with 
supi)uration. 

Among  English  writers,  Murchison,  in  his  work  upt)n  the  liver 
(third  edition),  notes  the  occurrence  of  rigors  in  chronic  obstruction, 
and  in  his  paper  upon  conditions  causing  an  intermittent  fever,^  he 
deals  more  fully  with  the  general  features  of  the  affection.  Harley, 
in  his  work  on  the  liver,  does  not  mention  it.  Ord  refers  to  it  in  his 
paper  on  some  of  the  rarer  symptoms  produced  by  gallstone.^  In 
the  English  text-books  on  medicine,  it  is  not  often  sjioken  of;  even 
Fagge,  whose  work  is  such  a  store-house  of  clinical  facts,  has  no 
reference  to  the  subject. 

In  this  country,  the  question  has  been  discussed  by  Bartholow,  who 
gives,  in  Pepper's  System  of  Medicine,  a  full  summary  of  the  French 
observations.  In  Sajous'  Arauial  for  1888,  Dr.  W.  H.  Thompson, 
of  New  York,  rtlers  to  intermittent  hepatic  fever  as  oceuji'ing  fre- 
quently in  this  country  and  as  well  recognized  by  authors;  but  in  a 
private  communication  he  informs  me  that  he  had  been  under  a  mis- 
apprehension, and  so  far  as  he  knows  the  subject  had  not  been  discussed 
by  any  American  writer.  Musser,^  of  Philadelphia,  has  reported 
several  interesting  cases. 

The  following  cases  have  been  under  my  observation  : — 

Case  I. — Jaundice  of  three  years  duration.     Repeated  attach  of  c hills 
and  fever;  chohemia,  death.     Gallstone.^  in  common  dmt. 

J.  H.  R.,  aet,  68,  admitted  to  the  Johns  Hopkins  Hospital,  May 
25th,  1889,  complaining  of  jaundice,  chills  and  fever,  which  had 
lasted  on  and  off  for  three  years,  ^yith  the  exception  of  attacks  of 
eczema,  he  had  been  a  healthy  man  until  three  years  ago,  when  his 
present  trouble  began  with  dyspepsia  and  pain  in  the  pit  of  the 
stomach.  In  the  first  attack  there  was  sharp  pain  in  the  epigastrium, 
followed  by  a  chill  and  vomiting.  These  recurred  very  frecpiently, 
and  with  them  he  invariably  became  deeply  jaundiced  and  the  stools 

'Lancet,  1879.  '^British  Medical  .Journal,  18S7,  I. 

•'  On  i'aroxysmal  Fever,  nut  Malarial.    Proceedingts  of  the  Tliila.  Co.  Med.  Society, 
1884. 


)t  appear  tt) 
ce  demands, 
pie,  .speak  of 
oeiati'd  with 

)n  the  liver 
obstruction, 
it  fever,^  he 
n.  Harlcy, 
s  to  it  in  his 
Istone,^  In 
en  of;  even 
lets,  has  no 

tholow,  who 
'  the  French 
Thompson, 
:'uri'ing  fre- 
s ;  but  in  a 
iider  a  mis- 
en  discussed 
las  reported 


icks  of  chills 
hid. 

spltal,  May 
Avhich  had 

f  attacks  of 

),  when  his 
pit  of  the 

'pigastrium, 
frecjucntly, 

d  the  stools 

,  18S7,  I. 

,  Meil.  Society, 


were  putty  colored.  He  had  been  subject  to  catarrh  of  tl,c  stomach 
and  had  always  been  constipated.  The  attacks  of  chills  and  fever 
had,  at  times,  been  very  severe,  and  he  would  sweat  heavilv  after 
hem  0„  the  occasion  of  his  first  visit  to  Hospital  a  Violent 
attack  came  on  whde  he  was  in  the  waitin<,-room  ;  he  shook  as  in  an 
ague  paroxysm.  His  ^^•ife  state.l  tluit  he  had  rarelv  passed  throe  weeks 
witliout  a  chill  of  great  severitv. 

Present  concUtlnn.-Uuch  emaciation  ;  skin  drv  and  harsh  and  of 
an  nitenscly  bronze  color.     It  presented  manv  snlall  scabs,  the  rcstdt 
of  scratching-^     The  muscles  were  very  flabby.     The  conjunctivae  and 
mucous^membrane  of  ti,e  mouth  were  stained,  as  were  also  the  nails 
of  the  fingers  and  ^.r^.     The  expression  of  flu.  face  was  dull  and  the 
speech  slow.     A:       ,  :d(m  was  impaired  from  dryness  of  the  mouth 
Jl^xamiuation  of  ...  uioracic  organs  negative.     Pulse  68,  small  and 
regular      Abdomen   w.s   a   little  distended,   somewhat  tympanitic 
everywhere  painless.  ' 

The  edge  of  the  liver  could  not  be  felt.     Dullness  in  mammarv  line 
began  at  the  (5th  rib  and  extended  2.\  inches  (C+  cm.)  verticallv    '  The 
most  careful  palpation  could  not  discover  the  gall  bladder      The 
splen.cdullness  was  slightly  iucreascrl,  b„t  the  edge  was  not  palpable. 
The  urine  was  of  a  deep  brownish-red  color,  acid  in  reaction,  specific 
gravity  1008.     It  contained  a  small  amount  of  albumen  and  a  few 
tube  casts.    Temperature  on  admission  was  98°.    His  chief  complaints 
were  of  intense  itching  of  skin  and  of  occasional  pains  in  the  abdomen 
On  the  morning  of  the  20th  he  had  a  chill,  in  wlu,.],  the  tempera- 
tun>  rose  to  101°  .nd  he  became  delirious,  would  not  answer  questions 
and  wantal  constantly  to  get  out  of  bed.     The  temperature  sank  to 
about^96°  and  remained  at  that  point  until  eleven  o'<-iock  when  it  rose 
to  97°.     (Gradually  coma  supervened  ;  the  pulse  rate  increased  to  160 
and  the  respiration  bcame  very  irregular,  :',0  per  minute.     He  was 
given  an  active  purge  luid  sAvcated.     The  coma  gradualh-  deepened ; 
the  temperature  rose,  icuchiug  towards  evening  101  °.     Ho  died  earlv 
on  the  morning  of  the  27th.  ' 

From  his  history  and  the  repeated  attacks  of  hepatic  intermittent 
lever  extending  over  a  period  of  three  years  (a  period  of  sufficient 
length    to   exclude   suppurative   cholangitis,  abscess,  or   cancer),   I 
made  a  diagnosis  of  obstruction  of  the  common  duct  bv  gallstones 
and  suggested  to  him  the  propriety  of  an  operation.     To  this  he  had 


I 


lii 


6 

given  his  consent,  and  entered  the  Hospital  with  a  view  of  remaining 
a  week  to  gain  strength  l)etor(>  submitting  to  it. 

P()Kt-}[ni'tcin,  by  Dr.  Welch.  Peritoneum  contained  30  cc.  of  yel- 
low serum. 

In  thorax  the  pleural  membranes  were  normal.  The  j)ericardium 
contained  an  excess  of  fluid.  Tlie  heart  was  a  little  cnlarjred,  weighing 
in  oz.  (;>2()+gms.)  The  segments  of  tlie  aortic  valve  were  indura- 
ted along  free  and  attached  margins.  On  the  aortic  aspect  of  one 
segment  was  a  iresli,  reddish-grey,  partially  d(;tached,  vegetation. 
The  remaining  two  segments  had  coalest^ed  in  consecpience  of  ulcer- 
ation and  nearly  total  disappearance  of  the  septum,  in  the  situation 
of  whicli  was  an  irregularly  indurated,  idcerated,  slightly  elevated 
ridge,  j)artially  covered  with  red-grey  frcsli  vegetations.  On  the 
ventricular  aspect  of  this  fused  segment  was  a  vegetation  loxH)  mni. 
Tli.e  mitral  and  other  vaKes  were  normal.  The  heart  muscle  was 
flabby  and  brownish  in  color;  ou  microscopical  examination  not 
fatty. 

The  lungs  were  normal. 

The  spleen  was  15  cm.  long  and  10  cm.  in  breadth.     Its  contents 
were  soft  and  dark  red  in  color. 

The  combinixi  weight  of  the  kidneys  was  about  12  oz.  (.'340+ gms.) 
Cortex  of  average  thickness.  The  striju  (;l)scured ;  organs  not  lii'm. 
Bile  duct.  Th(>  oi'ificc  of  the  common  duct  was  dilated  and  con- 
tiiined  a  ])lug  of  thin,  |>ale  yellowish  mucus,  easily  dis])!aced.  Upon 
passing  a  probe  i.-to  the  duct  it  entered  a  sac  1 J  cm.  from  the  orifice, 
which  correspcmded  to  the  dilated  ductus  communis  choledochus.  A 
round  ulceratin.!  opening  3  mm.  in  diameter  communicated  between 
the  lumen  of  the  duodciumi  and  the  common  duct  in  its  course  in  the 
intestinal  wall.  A  sac  resulting  from  the  dilatation  of  the  common 
duct  measuring  '2%  cm.  in  diameter  was  completely  fill(>d  with  gall- 
stones of  varying  sizes,  the  largest  being  2  cm.  long  bv  J ,',  thick  • 
he  smallest  not  larger  than  a  ])ca.  All  were  provided  with  facets. 
The  walls  of  the  dilated  common  iXw.t  were  thickened  and  the  sur- 
rounding connective  tissue  very  dense  arid  intimately  adherent  to  the 
adjacent  [)arts.  The  gall  bladder  \\as  shriuik(>n  to  a  small  sac  2  cm. 
in  length  by  2  cm.  in  breadth.  The  walls  were  thickened  and  it 
cimtained  a  number  of  gallstones  ansund  which  it  had  contracted. 
The  cystic  and  hepatic  ducts  were  greatly  dilated  and  contained  gall- 


^  ,'h 


)f  remaining 

10  CO.  of  yel- 

poriciU'diiim 
}d,  wij^liiiig 
vorc  iiuliirii- 
[)ec(  of  one 
vegetation, 
ice  of  ulcer- 
lic  situation 
tly  elevated 
IS.  On  the 
15x10  nun, 
nmsele  Avas 
inatioM   not 

[ts  contents 

.•340+  gm.s.) 
IS  not  linn. 
(1  and  con- 
ed. Upon 
the  orifice, 
Jocluis.  A 
ed  between 
)ni'se  in  tlie 
le  common 
with  gall- 
1!  thiclc; 
aith  facets. 
id  the  sur- 
M'ent  to  the 
1  sac  2  cm. 
ned  and  it 
contracted, 
tained  gall- 


stones;  a]tog(>t]icr  not  less  than  twenty  conld  i)c  felt  in  the  dnct. 
Externally  they  were  deep  hlack  in  color. 

The  liver  weiglied  S  ll,s.  11'  ,.z.  (I68(5.S  gms.) ;  the  surface  was 
smooth,  mottled  greenish  and  ])ale  yellow  in  coh.r.  Outlines  of  the 
lobules  were  indistinct. 

On  section  the  bile  ducts  appeared  moderately  dilated.  The  walls 
were  thickened  and  tlie  .-outcnts  yellowish,  vis("i(l,  and  not  purulent. 

Tile  aorta  presented  several  small  atlicromatous  ulcers. 

Case  U.—Jlistnn/  ,>f  prrnmis  alffid:^  of  ;/,ulxti,ne  ro/ir.      For  ru/ht 
monfJi.^  m:an-in<i  affwks  ,>f  j,ni,i   with  a;/ur-/;ir  pm'o.ri/.-^,ii.s  and 
iiilcmfmttion  offhrjaniidirr.    J\,.'^.,a;/r  nftlH-r/a/Moiie.    Rrmrcn/. 
X.  K.,  act.  ;',0,  a  dark,  slightly  built  woman,  was  admitted  to  the 
Montreal  General  Hos])iiaI  November  17,  1,S79.    She  had  been  hcalthv 
with  the  exception  of  o.'casioual  attacks  of  indigestion.     Fom-  vears  be- 
fore she  had  several  attacks  .-.f  cramps  in  tlic  alidomen.     In  th'c  middle 
of  September,  1,S70,  they  recurivd  after  a  welting.     At  this  time  she 
l.ad  vomiting,  and  the  attacks  were  of  such  severity  that  morphia  was 
given  hypodermically.     Two  days  after  the  onset  she  became  deeply 
jaundiced,  the  attacks  of  pain  recurred,  and  the  vomiting  became  very 
troublesome,  but  in  about  two  weeks  she  was  al)le  to  go  to  her  home, 
where  she  remained  until  November  ]7di.     ^Mleu  admitted  she  was 
deeply  jaundiced,  the  tongue  was  furred,  she  liad  nausea  and  looked 
fcei)le.     She  remained  in  hospital  during  th(>  winter,  and  I  found  her 
in  Wanl  2.3  when  T  went  on  duty.     During  a  residence  of  five  and 
one-half  months    in  liospitid    her  chief  symptoms  had  'oeen  :  first, 
jaundice,  varying  greatly  in  iiiieusity,  sometimes  almost  disappearing, 
but   recurring  again  in  a  few  days;  second,  ague-like  paroxysms- 
chills,  fever  and  sweating — accompanied  by  severe  abdominai  pains, 
coining  on  at  intervals  of  from  three  to  ten  days;  third,  great  impair- 
ment of  a])petite,  dyspepsia,  frcfpient  vomiting,  especially  about  the 
time  of  the  paroxysms;  fourth,  great  tenderness  in  the  epigastrium, 
most  marked  over  the  right  c(;stal  border. 

After  an  interval  of  a  week  or  ten  days — during  which  the  jaundice 
would  diminisli,  tlie  bile  almost  entirely  disappear  from  the  urine, 
theficces  become  slightly  l)ile-tingcd,  the  appetite  improve,  and  the 
patient  would  sit  up— the  paroxysm  would  come  on,  either  with  a 
slight  chill,  not  more  perhaps  than  a  transitory  feeling  of  cold;  at 


i      !i 

i 

i 

f 

8 

otliers  it  would  ho  a  severe  rij^or,  i„  which  she  would  sludge  as  if  in  an 
ague-ht.     This  cold  shxgo  lasted  from  fifteen  minutes  to  three  or  fmu- 
liours  and  was  followed  by  great  heat  of  the  skin  and  hnrniuu-  fever 
wJueh  after  eontiuuing  for  an  hour  or  two  would  be  followed  hv  " 
profuse  perspiration.     The  tem,,e.-at,n-e,  whi,.],  was  usuallv  normaf  or 
even  sub-uornial,  would  rise  in  the  attaeks,  readiino'  1()2°-104°  sub- 
SKl.us  (puekly  after  the  paroxysm,  and  sometimes  sinking  to' 1»7° 
The  fever  mrely  persisted  for  an  entire  day.     Among  the  eoneomi - 
tant  symptoms  of  these  attneks,  vomiting  with  severe  gastric  nain 
were  the  n.ost  <.ommon.     The  pniu  whi,.h  usually  gave  indication  of 
the  onset  resembled  that  of  hepatic  coli,.,  being  e,,igastric,  and  radi- 
ating to  a  p.,u.t  beneath  the  right  shoulder  blade.     It  was  scarcely 
ever  as  agonizing  as  the  pain  of  ordinary  biliarv  c<.]ie,  but  was  often 
severe  enough  to  require  morphia.     Before  and  after  tlu"  attacks  the 
eiMgastrium  was  very  tend,.-,  so  much  so  that  she  would  even  com- 
plain of  the  weight  of  tlie  bed  c-lothcs.     Vomiting  was  a  marked 
teature,  and  usually  aceomimuied  the  paroxvsm.     The  bowels  were 
moved  every  day,  sometimes  t^vo  or  three  motions.     The  color  of  the 
fa^ees  depended  on  the  intensity  of  the  jaundice-light  color  ^^•hen  the 
skui  was  deeply  tinted;  broAvnish  when  the  color  of  the  skin  was  less 
intense. 

For  a  long  time  the  motions  were  filtered  in  the  hopes  of  finding 

gallstone^.     Invariably  after  an  attack  the  jaundice  deepened,  and 

we  could  g,.nerally  tell   by  her  ap,>eanuuv  alone   ^vhether  she'  had 

had  one.      fhe  urine  also  at  this  time  became  deeply  bile-tinged.     In 

the  mterv^ls  the  pain  subsided,  and  the  nausea  and  vomiting  beca.ne 

ess  troublesome,  but  for  days  she  ,.ould  not  take  anvthino.  b„ta  little 

biscuit  and  milk.     She  usually  remained  in  bed,  but  during  a  long 

interval  she  Mc.dd  get  up  and  go  about  the  xvard.     Itching  of  the 

skin  was  occasionally  a  distressing  symptom. 

In  A])ril  I  made  the  following  notes  : 

"  Moderate  jaundice  ;  nothing-special  to  be  seen  on  inspoct^.u  of  the 
abdomen  ,•  on  palpati.,n  decided  tenderness  in  the  epigastric  region 
most  marked  towards  the  right  costal  border ;  no  ftdlncss  or  increased 
resistance;  Innit  of  dullness  extends  in  nipple  line  from  u,,per  border 
of  6th  nb  to  w.thin  half  inch  (l.;j  cm.)  of  the  margin  of  tJ  rib  • 
splenic  didlness  2^  inches  (6.3  em.)  ;  heart  and  lungs  normal ;  nrinj 
bile-tnigcd,   specific  gravity   1020,   no  albumen;   enormous  dark 


n 


ke  as  if  in  an 
three  or  f  J  mi- 
ll rniu};'  fcvor, 
)1  lowed  by  •: 
ly  normal,  or 
°-104°,  sub- 
bing to  97°. 
lie  eoneomi- 
jrastric  jiaiii 
udication  of 
<',  and  radi- 
vas  scarcely 
it  was  often 
attacks  the 
even  com- 
■i  a  marked 
)OAveIs  were 
color  of  the 
>r  when  the 
:in  ^vas  less 

of  finding 
pencd,  and 
?r  she  had 
iiiged.  In 
ng  became 
but  a  little 
inji'  a  long 
iiig  of  the 


t'onof  the 
•ic  region, 
'  increased 
aer  border 
'  tl  rib; 
al ;  nrinc 
)Ms   dark, 


grannlar,  bilc-staiiicd  casts,  some  containing  epithelial  cells;   fieees 
day-colored,  soft  and  a  little  offeiisive  ;  no  lever." 

Towards  the  en.l  of  April  she  left  the  hospital  and  Mcnt  to  her 
home  at  St.  Johns,  where  she  was  attended  bv  Dr.  Robert  Howard, 
who  treated  her  for  gallstones,  giving  large  doses  of  bi-carbonate  of 
potash.  She  had  several  j.aroxysms  of  pain  with  ii>ver,  an<l  the 
jannd,ee<.o,.tnined.  On  .Inne  3rd  she  passed  perannma  large  n.nnd 
gallstone,  whic-h  Dr.  Howard  kindly  sent  to  me.  It  weighed  GO 
grams  (;].9  gnis.),  and  incasnrcd  a  little  ovei'  one  cm.  in  diameter 
She  improved  very  rapidly  after  this,  the  ,jaun<lice  disappear,.!,  and 
she  recovered  her  usual  health  and  strcn-tii 

Case  III.— /Vom  ./>,/>/,  mV,  unfU  Amjmt,  J882,  jmnxlhr  of  vary- 
mg  intemltij,  "'ith  recurring/  attack,  of  pain  and  intermittent  fever. 
Recovery. 

November  9, 1 880, 1  M-as asked  tosee  Mrs.  S.,  act.  5o,  a  well-nourished 
woman,  wife  of  a  florist.  She  had  alwavs  been  hcalthv  and  had 
borne  five  children.  Had  been  acc-ustomed  to  work  in  the  garden  and 
m  the  greenhouses.  Her  illness  began  July,  1879,  and  her  phvsician, 
Dr.  Sunpson,  gave  me  the  following  particulars  of  the  onset  and 
development  of  the  disease. 

"In  July,  1879,  Mrs.  S.  consulted  me  at  her  house  for  a  mild 
attack  of  Jaundice,  which  she  ascribed  to  having  seen  a  disgusting  object 
which  emitted  a  most  otiensive  odor,  causing  her  to  feel  sick  at  her 
stomach.    When  a  young  girl  sli(>  had  an  attac^k  of  jaundice  following  a 
fright.     On  August  4th,  I  saw  her  again  ;  the  jaundice  had  deepened  and 
she  comijlaiued  of  a  dull  pain  in  tii.>  irgion  of  the  liver  and  general  dis- 
tress.   She  remained  in  this  state  until  the  morning  of  the  6th,  when  she 
was  seized  with  a  severe  chill  and  int(>nse  ]iaiu  below  the  ribs  on  the 
right  side,  extending  into  the  epigastrium  and  to  the  right  shoulder. 
It  was  iiUTeased  by  pressure  and  motion,  the  breatliing' was  hurried 
and  the  anxiety  of  the  patient  most  distressing.     A  chill  of  about 
two  hours  was  followed  by  high  fever,  then  copious  sweating,  which 
stained  the  sheets  a  deep  yclh.w  color.     The  liver  was  distinctly  en- 
larged.    The  pain  gradually  abated  l)ut  the  tenderness  ])ersiste"d  for 
several  days.     All  the  essential  phenomena  of  jaundice  were  present. 
She  remained  under  my  earc  until  January,  and  during  this  time  she 
had  a  paroxysm  every  two  or  three  weeks,  varying  somewhat  in  in- 


10 

tensity  and  d.u-ati„„.  The  pain  ^mdmUy  boca.no  loss  and  loss.  The 
chdl  fovor  and  sweating  wore  invariably  present  aftor  each  attaek, 
and  thejaund.oe  deepened.  Itehino-  ..f  the  si<in  uas  a  most  distre..^ 
ing  symptom,  preventinjr  sleep  and  .•onderin.u-  lif.'  abnost  unencbnable 
1  <..■  days  at  a  time  the  stools  wore  strained,  but  without  finding  sall- 
.'^tonos.      ihe  enlaro:,.ment  of  the  liver  disappoarod  " 

During  the  early  part  ot^the  y,>ar  the  atta.-ks  oontinnod,  but  durin.. 
the  summer,  under  homreopathio  treatment,  the  jaundiee  abnost  dis- 
appeared, and  tor  many  weeks  sh<.  had  not  a  paroxvsu,.     Wh<.n  first 
1  saw  her  si.e  was   intensely  ja.mdieed  and  suffere.!   with  the  most 
^err.ble   .tclung  of  the  skin    whieh   I  have  ever  witnesse<l.     Warm 
a  kabue  baths  were  ordered  with  great  benefit.     One  night  after  a  bath 
she  beeame  .u.te  MH.oherent.     On  examination,  her  condition  was  as 
f.Wlows  :  w,«ll-nounshed,  somewhat  stout  woman  ;  thi.'k  hv.v  of  pan- 
"•••"Ins  over  the  abdomen.     She  says,  however,  that  she  has  lost  flesh 
d.H-,„g  the  past  year.     The  skin  has  a  deep  greenish-yellow  tint,  and  is 
coveied  w.tli  scratehos ;  edge  of  the  liver  eould  not  be  felt;  nJtumor 
evident  below  the  nght  costal  border  ;  she  win,.es  when  firu.  pressure  is 
made  between  the  navel  and  costal  margin ;  area  onWev  <lulluoss  some- 

w. at  dnnnushcKl  and  iho  organ  isnottendert,,flrmpross.n-e;thesplenie 
^I"  In.'ss  IS  increase.!,  7  inches  in  vertical  diameter  (17.8  cm.);  heart 
and  luugs  nornud  ;  tongue  red  and  in,le„te,l  with  the  teeth  ;  bowels 
irregulai- ;  stools  <.lay-colored  and  oifLnsive  ;  urine  verv  dark-colored 
and  contained  inuch  bile  pigment ;  temperature  9S.4° ;  appc^tite ,  „ .or  .m  ' 
only  take  soft  fo.l.      Within  a  few  davs  the  itching  diLppeircd,  ev- 
ccpting  on  the  palms  of  the  hands  and  the  soles  of  the  feet.     Tho^e 
parts  had  ahvays  bc^en  the  most  troui>k.some,  and  the  pads  at  the  bases 
of  th<,  hngers  were  mu<-h  sw,.llen  and  ton.ler.     Bv  the  loth  she  was 
v.1,^  much  better.     The  Jaundice  had  begun  to  disappear,  but  at  noon 
on  the  l(,th  slie  had  a  very  severe  paroxysm,  the  chill  lasting  noarlv 
two  hours  and  there  was  no  vomiting  with  this  attack  and  no  spc^iJl 
abdominal  pain  ;  no  chaug<.  noticed  in  the  hepatic  region 

Ironithis  time  until  Christmas  day  she  had  seven  severe  attacks, 
varying  ,n  intensity,  five  of  which  followed  eac-h  other  on  Frhh.vs 
The  rigors  were  most  intense  in  violence,  shaking  the  bed  and  causin.. 
the  room  to  vibrate.     Temperature  reached  fnmi  103°  to  104°      The 
jaundice  intensified  after  each  attack. 


11 


104°.     The 


After  Chi-istinas  she  improved  very  much  ;  jaundice  almost  entirely 
disappeared  and  she  was  able  to  get  up  and  go  ah'  ut  tlie  house.  On 
two  oeeasiouH  she  had  scnere  headache  and  great  depression,  tolh.wed 
by  (H.pious  sweating.  Tlie  palms  <.f  the  hand  continued  verv  tender. 
A  ti-oul)lesome  sympttmi  was  tlie  pn.l'use  sweating  ahout  the  waist, 
sufficient  to  saturate  the  under-linen  and  render  it  neeessarv  to  wear 
cloths  ai)out  her.  The  urine  became  <-lear,  the  freces  contailied  bil(>; 
the  liver  showed  no  special  aheration.  The  tenderness  on  the  i-i-ht 
side  of  the  epigastrium  persisted.  During  the  spring  of  1881  the 
daily  amount  of  the  ure;i  was  estimated  during  a  period  of  three  weeks, 
but  there  was  no  special  diminution  during  (lie  paroxysms. 

I  lost  siglu  of  :\Ir.s.  S.  after  the  spring  of  1881,  when  she  was  still 
considerably  jaundiced  and  had  paroxysms  at  prolonged  intervals. 

On  the  7th  of  .July,  18S2,  she  came  to  see  me  and*  stated  that  her 
condition  had  reimiined  unchanged;  the  paroxysms  still  ivcurrcd  at 
intervals,  but  she  once  ])asscd  six  weeks  without  one.  In  May  of  this 
year  she  had  them  worse  than  ever,  and  to  use  her  own  expression, 
"she  was  dead  of  them."  After  August,  188l2,  the  jaundi.^e  dis- 
a])])eared  and  sIk;  now  looks  in  i)erfbct  health. 
_  Dr.  F.  G.  Finley,  of  Montreal,  iwcntly  (Oct.  1888)  made  in.pii- 
ries  for  me  about  this  patient  and  writes  that  she  continues  well  and 
has  had  no  return  of  the  i)ain  or  of  the  jaundice. 

Cask  1  \.— Repeated  (itlaeks  of  hilian/  colic.  For  three  months  jaun- 
dice toith  repeated paroxymiiH,  ch Hh,  fever  and  sweats!.  Operation. 
Death.      Galidoiie  in  common  duct. 

Mrs.  S.,  act.  51,  patient  of  Dr.  tolling,  of  Chestnut  Hill.  Seen 
March  2d,  1887. 

She  had  been  a  healthy  woman,  but  since  1862  had  several  attacks 
of  biliaiy  colic,  on  one  occasion  with  jaundice.  Since  Christmas  she 
she  had  pain  in  the  upper  part  of  the  abdomen,  and  very  severe  jaun- 
dice, which  has  gradually  deepened.  The  urine  has  been  intensely 
bile-tinged  and  the  faves  day-colored,  h^or  two  weeks  she  had  been 
woi-se  and  confined  to  bed.  A  special  f 'atm-e  had  been  chills,  recur- 
ring ckily,  followed  by  fever  rising  to  103°  and  104°,  and  then  copious 
sweating.  The  chills  were  most  severe  and  the  fever  most  pungent. 
The  stools  had  been  carefully  examined  Ibr  gallstones,  but  without 
result.     The  patient  was  a  well-built,  well-nourished  woman,  with 


1   t 


il 


i 

.] 

r 

"    '  i 

■■   1 

i.il 


12 


.  I 


'a ' 


» I 


t. 


t,        / 


.M 


intcn.so  ictcnis  ;  toiif^uo  coated  und  dry  ;  pulse  120,  smsdl  and  focble; 
no  iWvr;  abdomen  lar^e  ;  iiit  al.undant  ;  liver  didlness  not  increased. 
On  palpation,  nothinjr  to  bo  delected  along  tlie  costal  border  in  the 
right  liypochondrinm  ;  towards  the  epifrastrium  great  tenderness  and 
(listinct  sense;  of  increa.^ed  resistance.  A  most  caieful  examination 
failed  to  reveal  the  presence  of  enlargement  of  the  gall  bladder.  The 
history  of  ilie  |)rcvious  attacks,  the  persistency  of  the  |.ivseii,  (me,  and 
the  recnrrencc  of  intermittent  lever  pointed  .lairly  to  obstruction  of  the 
ducts,  probably  by  gallstones.  Tlie  qnestion  of  snrgical  interference 
was  raised,  and  possible  obstruction  by  malignant  disease  at  the  head 
of  the  pan(;reas  was  also  debated. 

March  ;Jd.  I^hc  patient  was  seen  at  2  p.  m.  by  Doctors  Agnew, 
J.  W.  White,  and  tolling.  The  condition  was  worse.  The  patient 
was  weaker ;  tongue  very  dry;  abdomen  distended;  diffuse  tender- 
ness, and  in  the  epigastrinm  extreme  sensitiveness  to  pressnre. 

Dr.  Agnew  made  an  incision  between  six  and  seven  inches  (IG  cm.)  in 

length,  the  outer  edge  meeting  the  rectus  muscle.    When  th<-  peritoneal 

cavity  was  opened  a  bile-tiiiged,  slightly  turbid  fluid  escaped.     The 

liver  looked  very  dark,  and  a  conical,  pointed  gall-bladder  projected 

beyond  the  edge  not  more  than  (.ne  inch  (2.5  cm.)  from  the  surface,  the 

liver  being  slightly  atrophied  above  it.    On  lifting  the  liver  the  bladder 

was  seen  to  be  enormously  dilat(>d,  and  by  aspiration  18  oz.  (431  gms.)  of 

dark  bile  were  removed.     There  were  no  gallstones  in  it,  but  a  stone 

was  felt  low  down  in  the  eonunon  duct  and  pushed  back  into  the 

gall  bladder  and  removed.     The  head  of  the  pancreas  seemed  hard 

and  indin-ated  but  not  enlarged.     The  patient  sank  and  died  twelve 

hours  after  the  operation.     Xo  autopsy  was  allowed. 

Case  Y.—Jaumlice  of  two  and  a  half  years  duration.  Iteearr'mg 
attacks  of  intermittent  fever,  with  pains.  Operation.  Death. 
ihdl>ito)ie  in  the  common  dud. 

A.  B.,  a  woman  aged  40,  was  in  the  Philadelphia  Hospital,  Sep- 
tember, 1887,  when  I  took  charge  of  the  wards.  She  had  been  under 
my  care  previously,  in  the  spring  of  1887,  wluui  I  was  on  duty  for 
Dr.  Tyson.  This  had  been  her  third  or  fourth  admission  within  two 
years  with  attacks  of  pain  in  the  region  of  the  liver,  and  chills,  fever 
and  heavy  sweats.  My  colleagues  had  on  t\\o  occasions  broudit  her 
blood  to  me  for  examination,  the  existence  of  malaria  having  been 


1.3 


susiHX-ted.  Once  certainly,  possibly  twi.v,  her  liver  was  aspirated, 
the  m'lirrinjr  chills  haviii<r  aroused  a  suspicion  of'ahseess. 

The  patient  was  a  nicdiuni-sizcd,  fairly  well-nourished  wonum.  She 
had  lived  a  hard  life  and  had  had  speciHe  disease.  Attacks  similar 
to  those  from  which  >he  at  present  sutfcred,  .anie  on  ahouf  two  years 
ago  and  she  had  not  been  entirely  free  finm  them  for  a  period  of  three 
months,  n..r  does  she  think  that  >li.  had  i„  this  time  ever  passed  two 
months  without  a  slij-ht  tin-e  of  jaumlic...  When  first  seen,  she  was  up 
and  about  the  ward  and  showed  only  the  slij-htest  leinon-tint  of  the 
ekin  and  of  the  conjunctivae.  The  urine  was  a  little  hinh-eolored. 
The  .stools  contained  l)ile.  On  e.vninination  the  liver  appeared  to  be 
enlarjred.  In  the  mammary  line,  the  nVht  h)be  extended  lour  fingers 
breadth  below  the  costal  margin  ;  in  the  median  line  a  distinct  irregu- 
larity in  oudine  could  be  made  out.  The  gall-bladder  could  not  be 
felt.  ^  Palpation  was  not  painfid.  Karly  in  ( )ctol).  r,  .she  had  an  attack 
of  violent  pain  with  vomiting  and  a  moderately  .severe  rigor,  after 
wliieh  the  temperature  rose  to  ueai-ly  104°.  and  she  sweated  pr..fusely, 
the  entire  paro.xysms  lasting  over  twelve  hours.  The  next  day  she 
was  di.-^tinctly  jaundiced,  free  from  fever,  the  tongue  heavily  coated 
and  the  stomach  extremely  irritable.  The  urine  was  very  dark,  con- 
taining bile-pigment  and  the  stools  were  light-colored.  The  liver  did 
not  seem  to  be  larger  but  it  was  sensitive  to  pressure.  The  gall- 
bladder could  not  be  felt. 

In  three  or  four  days,  the  gastric  .symptoms  passed  awa\-  and  she 
was  ai)le  to  sit  up.  The  jaundice  deepened  distinedy  for  three  or  four 
days  and  then  gradually  liglitened. 

The  case  was  made  a  subject  of  almost  daily  demonstration  in  the 
ward-class  and  I  etmfidently  predicted  a  return  of  the  j)aroxysms. 
Throughait  the  winter  she  had  fbur  or  live,  each  similar  to  the  one 
just  described,  varying  somewhat,  however,  in  Intensity, 

I  had  r  .ade  up  my  mind  from  the  length  of  time  which  the  woman 
had  suffered  and  from  the  character  of  the  attacks  that  the  case 
was  one  of  obstruction  of  the  common  duet  by  gallstone ;  and  early 
in  February,  I  asketl  Dr.  AVhite  to  see  her  in  consultation.  The 
patient  consented  to  an  operation,  and  Dr.  White  made  a  free  abdomi- 
nal incision  along  the  line  of  the  costal  cartilages.  There  was  exten- 
sive perihepatitis  with  [)ucivering  of  the  edges  of  the  liver,  due  to 
the  cicatrization  of  old  gummata.    The  gall-bladder  was  not  enlarged ; 


■    I- 


I  11 


ill 


14 

tliorc  was  ji  jrivat  dciil  of  fibroid  matting-  of  the  tissues  in  the  },mstr()- 
ln'patic  (.mciitiim.  No  uallstonc  coiild  l.<.  tilt  in  llio  ^rull-l,l;,d,|,.,.,  nor 
in  the  diirt.  The  patient  came  oiil  well  Iroin  under  the  intliienee  of 
(ithvv;  had  no  shock,  and  six  hours  afterwards  lier  temperature  and 
pulse  were  norinal.  Tiie  folh)\vin^r  day  tlierc  was  a  rise  of  tenipom- 
ture  and  slie  died  on  tlie  third  day  a  Her  the  operation. 

1  had  l)eensoeonlideut,  from  the  hi>tory  of  tiie  ease,  that  it  was  one 
•  )f  ol)struetion  hy  jiallstones,  that  I  was  naturally  chagrined  at  the 
negative  result  of  the  operation.  The  friends  removed  the  body  at 
onee  to  Jenkintown,  l.nt  I  was  Ibrtnnately  able  to  seeinv  an  autopsy? 
when  the  f  dlowing  condition  was  found. 

Perihepatitis  with  deep  |  tucker  ing,  (.wing  to  the  eicatri/ation  of  old 
gunnnata.  'I'he  liver  was  not  enlarged  ;  the  appau-ut  increase  in  size, 
during  lil!-,  was  due  to  tlu;  tilting  forward  of  the  convex  surflice  of 
the  organ.  Tln^re  was  recent  acute  peritonitis,  confined  to  the  region 
above  the  transverse  colon.  The  liver,  stomach  and  duodenum  were 
removed  together  for  dissection.  On  slitting  open  the  duodenum,  a 
bde-tinged  nuicus  was  seen  oozing  from  the  papilla.  Projecting  into 
the  duodenum  and  covered  by  the  mucosa  only  was  a  gallstoiu',  the 
size  of  a  inarblf.  Ft  lay  entirely  within  tiie  bowel,  (piite  close  to  the 
narrow  orifice  of  the  duct,  through  which  it  could  be  >een  after  the 
removal  (tf  the  nnunis.  'I'he  stone  could  not  l)e  moved  up  or  down, 
though  it  had  slight  phiy  in  the  dilated  pouch,  at  the  term"',  it.m  of 
tlic  duet.  The  common  duet  and  its  main  branches  were  di!  ito  ;  tlie 
former  al)out  the  size  of  the  index  finger.  The  contents  of  iJie  duct 
Avas  a  bile-stained  nuieoid  fiuid.  The  cystic  duct  was  wide.  The  gall- 
bladder was  a  little  enlarged,  but  did  not  contain  any  stones.  Tlie 
terminal  bihvducts  were  not  dilated.  The  other  organs  presented  no 
s])ecial  change. 

Casp:  Yl.—JanndiW  of  vanjimj  intamty  from  Juli/,  1887,  until  Axi- 
(jud,  J 888.  Rcpcdtcd  pumxijsms  (f  hifermittcnf  fcrei:  Death. 
A.  B.,  act.  70,  physician.  Family  history  good  ;  has  enjoved  excel- 
lent health  with  the  exception  of  an  attack  of  nervous  prostration  in 
1863.  Some  years  after  he  got  stout  and  was  unable  to  take  i)roper 
exercise.  lie  never  had  a  strong  digestion  and  always  had  to  be 
carefid  in  his  diet.  He  was  in  his  usual  lieallh  until  July,  1887, 
when  he  had  an  attack  of  jaundice,  coming  on  with  severe  pain,  evi- 


!  • 


IT) 


it  il  \V!iH  one 
iiM'd  at  tlio 
lie  Ixtily  at 
ill!  autopsy^ 


(k'litlv  MUaiTcoIir.    Tl, 


in  fiv( 


<»r  MIX  weeks  witli  paiii^  nl"  t| 


jaiiiMliee  jriiuliially  disappeared,  Ian  ictu 


riled 


!<■    siliie   t;lianietei 


Tl. 


uttaelv  did  la.t  last  s,.  lui,u-,  |„„  i„  I  ),,.o,„lH.r  lie  had  a  third  attack 
oeialed  with  pain  in  the  upper  pcrtii.n  (.fthealxl 


•eeoiKl 
ami  in 


he   has  not   heeii   free   t'roin   tl 
greatly  in  intensity.     Ahont  Christn 


•  •men.     Since  then 
le  jaiindiee   mm.  !    has,  however,  varied 


by  fc 
I 


WIS  '.(•  had  a  ,-<  vere  chill,  followed 


ver  and  sweats 


lave  recurred,  and  after  each  < the  jaii 

loth,  when  I  >aw  the  patient  with  Dr.  M 


intci'va!>  of  ai.oiM  ten  A:    :*  the  paro.w; 


'HIS 


a.'^  follows  :  Stout,  well- 


•  d(c     ned.     On   March 
nrra       iic-ton,  his  condition  was 


iinnrished  < 


5)2,  feehh.  ;   no  f 


I  old   man  ;  deeply  janndin  <\  ;   pulse 


ever  ;  skin  nioist  ;  roniplaiiied  of  niiich  it 


clmijj' ;  tonuiie 


coated;  ahdoinen  laruc;  pannicnhis  thick;  omental  liit 
palpation,  the  cdo,.  of  the  liver  n..t  to  he  IMt ;  dullness  diniinishe.l 


excessive, 


more  than  three  linuvrs  hivadth  in  the  middle  I 


On 

not 

ine,  and  two  and  oue- 

iiie;  no  teiideriios  on  (h'cpest 


II"  inches  ((;.;}."i  cm.)  in  the   iiijiplc  1 
|.rcs>ure  over  the  pancreas.      Tl,,.  putieiit  was  hright  inentalh 
vomitiii-  had  occurred  thron.-lioiit  the  illness,  Imt  there  had  I 


ta( 


ks  of  nausea;  bowels  constipated;   stools  of  (I 
•  •olor  of  })iitty.     They  have  not   been  dark   and 
ance  for  months.      Trii 


K'cii  at- 


T"'lie  ninht  bclltre  I  s; 


le  scanty,  deeply  iiile-tiiiucd. 


le  consistency  and 
normal   in  appi'ar- 


iw  liim  he  had  a  vcr\ 


and  one-lial 


fi 


lioiir.- 
II 


wnic 


\\a>  1! 


oiiowed  hv  a  i)nrm 


-cvere  cliil 


iiig  iev 


asinii 


er  and 


one 


pro- 


use  sweatin-      lie  was  imich   prostrated  by  the  attack,  and  in  tl 
mornin-    as   was    iiHial    after    an    attack,    the  jaundi.r    had    deep- 
ened and  intensitied.      lie  was  not  emaciated,  thoiiol,  I,,,  .said  that  he 
had  lost  llcsh,  partictdai 


in  th 


1  saw  him  at  interval-  of  a 
April  he  iiad  no  chills  and 


le  limbs,  dnrino'  the  pa.-t  three  months. 
I'W  weeks  lor  several  months.     'I'liroiedioiit 


jaundice  bciran  to  liiihten.      Fn  Mav  he  had 


wa.-  com])aratively  comfortable,  and  th 


several  viay  severe  par- 


oxy.-m.s,  in  which  the  temperature  reached  J(»;',°-104°.    After  eacl 
the  color  became  more  intensified,  and  tl 
some  of  the  chills  he  had 


one 


complained  only  of  a  sen 


le  urine  became  darker.    With 
sovnv  abdominal  pains,  but  with  others  he 


sation  of  epijiiistric  di.stre.ss.  ThrouylK.ut  the 
summer  the  chills  an.Ltl'ver  persisted  at  irregular  intervals.  In 
Augu.st  the  jaundice  deepened  and  he  died  coinato.se.     No  autopsy. 


:  I  if 


i  <i] 


I  ff 


'  1 


a^SE  YIL—Jamdlce,  with  attack.^  of  co/ie,  often  (?)  //rar.s'  diimtinn. 
Under  observation  for  three  ,/ears,  with  repeated  attaeLs  of  inter- 
mittent ferer,  always  mnociated  with  an  increase  in  the  jaundice. 

A.  B.,  aged  40,  single,  domestic  by  oceu])ation,  was  admitted  to  tlie 
Pliiladclpliia  Hospital  with  fever  and  Janndiee. 

There  was  nothing  sjieeial  in  the  fiimilv  history.  Ten  \vi\v<  ago 
sIio  had  the  first  attack  of  Ja.mdiee,  whieh  came  on  with  pain  in  <he 
abdomen,  particnlarly  „n  th(>  riglit  side.  She  was  in  l)ed  for  two 
weeks.  From  that  date  nntil  tiie  present  the  skin  has  never  been  of 
the  normal  color,  thongh  for  weeks  the  Janndiee  wonld  l)e  extremely 
light.  Dnring  this  period  she  has  had  repeated  attacks  of  pain  in  the 
region  of  tiie  liver,  nsnally  aeeompam-ed  with  vomiting  and  diarrhoea 
In  <me  of  these  "spells,"  as  siie  calls  them,  she  was  admitted  to 
Hospital.  She  states  that  for  the  past  ten  years  she  has  had  on  an 
average  three  <.r  fl.nr  (jf  these  attacks  a  year,  always  associated  with 
chdls  and  fcNcr  and  with  sweats.  She  has  had  also  what  she  terms 
"bnrning  spells,"  in  which  she  would  get  very  hot  but  would  not 
sweat. 

Inspection.  Patient  not  emaciated.  There  is  a  thick  laver  of  fat 
over  th(>  abdomen  ;  tlu-  face  is  fairly  plumj) ;  she  is  deeply  jaundiced, 
color  of  dark,  olive-yellow,  not  th.e  light  soft  tint  of  recent  icterus 
The  conjnnctivie  are  deeply  stained.  The  skin  is  dry  and  harsh. 
There  is  no  eruption,  only  a  W^w  scratches  on  the  back.  She  com- 
plains of  intolerable  itching.  Temperature  was  103°  on  admission 
but  fell  to  the  normal ;  ,)ulse  100.  The  abdomen  is  symmetrical,  the 
upper  zone  not  especially  enlarged.  On  palpation  it  Avas  soft,  mm- 
resistent  and  painless  until  the  epigastric  ana  right  hvp.)chondriac 
regions  were  reached,  which  on  pressure  -vere  extremeh-  tender.  The 
edge  of  the  liver  can  be  felt  just  below  the  costal  margin.  The  gall- 
bladder is  not  paljiable. 

Percussi(m  in  mid-sternal  line  shows  not  more  than  two  inches  (5  era.) 
of  liver  dullness  ;  in  mpple  line  ,'>boiit  three  inches  (7.6  cm.). 

The  spl(H-n  is  not  i>alpable.  riiere  are  three  inches  of  vertical 
dullness  in  the  axillary  line.  » 

She  has  liad  several  movements  of  the  bowels  since  admission  ;  th(> 
faeces  are  soft  and  of  a  grayisii-brown  color.  Tiie  urine  is  high-colored 
and  contains  bile-j^igment,  no  albumen. 


17 

th^viuf '°|."T  ;'■'"'"■,'"■  ""■'■  ""  ""■"■  *l'"'-'"^  ""'>»-"»  during 
hioe  jeau,.  b,,!,  enne  »Ik.  „as  admittol  ,vitl,  (bvor  and  .™t  .,ain 
n  ti.o  -...gas,,.,,.  ,,.gi.,„,  .i„,  ,,„„i,i    ,  „„,  j,,„,,,^^^     Tl,.:„    IZ 

It  \;'''T ''■"'';';■''''■  '''■"'•'''■"'■''''•  TlH,  stool,  w  J  novo,, 
b  , Ik  „,,, I,  ,„.,■,.,■  ,,„,so,„.  T„i,,.  .1,0  „.as  mad,,  iho  sul,  ,■,  oC  a 
.  d  ,.t,,,„„g  a  „,.„,  of  lK,,a,i,.  i,„e,.,„i.tc.n,  ll.o,-,  da,.  i„     II  ,,1! 

alHlih  to  din.nic  ohstniction  l.v  oallstones. 

(inttjiici,      Jifcoirri/. 

P\^!ur    ;f'^-?."":  ^^•'"''''"'  ^"  ^''"  '"^^t-i^v  wards  of  the 
■  Uulel,  ua  H„„p,tal  ,u  January,  188<i.     He,-  lah..  was  „o..,nal  and 
t^    o„vaIo..v,H.e  UMn.ten.upt.d.     Two  ,nonths  alter  ..onH..c,.ent,  sh 
tell  across  a  ciaii- and  II  iirod  lini..„U'  i  •  ^j  •  "<- 

rh-,>r,.    ..,:,1  ,1  severely,  eausniix  a  profiise  Iiemor- 

rluge,  .said  to  liave  been  uterine.    Three  d-ivs  ntVor  fl„. ...;  i     .111 
„  1  .  .  lum  Uiusairei  tlie  aceulent  slie  lind 

naasea  and  vonut.ng,  an.l  in  the  eourse  of  a  week  jaundice  develo,  d 
When  admitted  to  the  nie<h-eal  ward,  she  was  sH,litlv  veliow  and 
oomplanied  of  pan,  ,n  the  epioast,-ium  rn,d  of  Iniek-adie."  Tl,<.  bowels 
were  const, pated  and  the  stools  of  a  elav  .oUm-  ;  thev  ^ve,.  f.vcp.enti; 
exa^.n.d  for  gallstones,  but  none  were  fbund.  A  few  weeks  aLr  tl. 
onset  of  the  ,auud,ee-the  exaet  date  is  not  stated  in  the  notes-she 
began  to  have  febr,le  attacks,  preceded  by  a  chill  and  fbllo^ved  by 
prof\,se  s.veat,ng.     These  attacks  ,vcur.-ed  at  i,-re.-ula.-  intervals      I 

though  that  she  had  ether  n,alaria  or  absc.ess  of  the  liver.  She  was 
repeatedly  made  the  s.ibject  of  ^va,•d-elass  demonstration  as  an  h.stance 
of  true  hcpat,e  .nte,-mittent  feve,',  p,,.bably  depending  upon  ..all- 
stoncs  obstr,u-t,ng  the  comnion  duct.  Exa.nination  of  tJie  liver'was 
negat.ve  ;  the  edge  ,.ould  be  distinctly  felt.  The  gall-bladder  did  not 
seem  to  be  enlargal.  There  ^vere  th,-ee  ineh<>s  (7.(5  e,n.)  of  ve.tical  liver 
d.illness  ,n  the  nipple  line  and  the  same  in  the  mid-sternal  line  The 
spleen  xvas  not  palpable.  Throughout  August,  she  had  four'severe 
olidls  ;  afler  each  one  the  jaundice  deepened  and  each  was  accompanied 
by  nausea,  vomiting  and  a  good  deal  of  pain.  In  September  the 
paroxysms  were  less  fre,,uent,  but  she  had  two  distinct  ,-igors,  on  the 
3d  and  on  the  L3th.     On  the   25th,  the  temperature  rose  to  nearly 


18 


^*;^wSi 


»  h 


102°,  and  she  had,  for  ton  days,  an  irrognhir  intermittent  ievor.  On 
the  2(1,  -id  and  4th,  there  were  ehills,  and  she  had  become  at  tliis 
time  more  intensely  jaundiced  than  at  any  period  since  her  admission. 
She  improved  between  the  oth  and  the  15th,  and  the  jaundice  got 
lighter.  On  tlie  latter  date  she  had  a  heavy  chill.  Chills  recurred 
on  the  22d,  2()th  and  the  ■J8th.  In  the  lirst  twelve  days  of  November 
she  had  six  rigors;  the  jaundice  again  became  dee])er.  After  this  date 
she  improved  very  much  and  through  the  latter  part  of  November 
and  the  early  part  of  December,  she  was  remarkably  well  and  j)re- 
sented  only  a  light-lemon  tint.  She  had  two  or  three  slight  chills, 
each  followed  by  an  increase  in  the  jaundice.  On  the  27th  and  28th, 
the  paroxysms  recurred  and  she  again  bei'amc  jaundiced.  Atter  Jan- 
uary 1st,  the  color  became  lighter,  and  by  the  18th,  when  she  went 
out,  the  jaundice  had  almost  disai)peared.  I  saw  her  again  more  than 
three  mouths  aftcwards  and  the  jaundice  had  comi)letely  disapj)eared 
and  she  had  had  no  recurrence  of  the  attacks. 

The  accompanying  temi)erature  record  of  Case  VIII  (.sec  p.  21)- 
illustrates  very  well  the  type  (jf  fever  met  with  in  these  eases. 

Of  these  eight  cases,  six  were  women.  Two  died  after  operation  ; 
two  died  I'rom  the  effects  of  the  long  coulinued  jaundice;  three  re- 
covered after  the  persistence  of  the  condition  for  I'roni  eight  months 
to  three  years,  and  (jne  passed  from  observation. 

In  analysing  the  syin]>tonis  asscjciatcd  with  these  paroxysms,  we 
have — 

First:  JdHndh-v.  This  was  present  in  everv  instance  and  may  be 
said  to  have  been  constant,  though  varying  very  greatly  in  its  inten- 
sitv.  It  will  have  been  noticed  that  in  every  one  of  the  cases  the 
statement  occurs  that  after  the  paroxysm  the  jaundice  invariably 
deepened.  I  do  not  remember  ever  to  have  seen  a  well-marked 
paroxysm,  with  intense  rigor  and  high  fever,  in  which  this  peculiar- 
ity 'lid  not  occur.  The  patients  soon  learned  to  recognize  it  and  to 
exi)ect,  as  a  matter  of  coinse,  an  intensification  of  the  jaundice. 
With  this,  the  amount  of  bile-pigment  increased  in  the  urine  and 
the  stools  became  more  clay-colored.  After  persisting  for  a  week  or 
ten  davs,  the  tint  would  become  lighter,  until  as  in  Cases  II  and  VIII, 
the  skin  would  l)ccome,  in  the  intervals,  almost  normal.  The  urine, 
too,  wonld  be  lighter  in  color  and  the  stools  contain  bile.     In  certain 


^'"f' 


19 


lever.  ( )n 
mo  at  tliiti 
admission. 
utHlice  got 
Is  rt'curred 
November 
or  this  (late 
November 
1  and  ju'c- 
igiit  chills, 
1  and  28tli, 
After  Jan- 
i  she  went 
more  than 
lisappeari'd 

[.see  p.  21). 
ses. 

operation  ; 
;  three  re- 
lit months 

xysms,  we 

id  may  bo 
1  its  inten- 
!  eases  the 
invarialdy 
ell-marked 
s  peenliar- 
e  it  and  to 
!  jaundiee. 
nrine  and 
a  week  or 
and  VIII, 
The  nrine, 
In  certain 


I 


Tkmpkkatcre  Kkcori).     (Seeih^) 


/ 


%■ 


'■ 

1 

i 

/ 

,^ 

•  f 

] 

'    n 

■'      , 

1 

1 

1 

1 

[i 

1 

' 

') 

ll 


20     ' 

of  tho  casps,  I,  III  and  VII,  the  jaundice  for  months  togetlior  was 
of  the  most  intense  <j:rado. 

It  is  possible  that  eases  of  intermittent  jn-rexia  may  oeeur  without 
jaundi('(>,  owing  to  ehroni(>  obstruction  of  a  main  duet  in  the  liver.  I 
liav(!  not  met  with  such  a  itase,  hut  Magnin'  refers  to  one  under 
Charcot's  care. 

Second  :  Fever.  Tliis,  in  well-develo])ed  jwroxysms,  begins  with 
a  sharp  rigor.  I  have  rarely  seen  in  intermittent  fever  chills  of 
greater  severity.  In  Case  III,  in  particular,  the  large,  stout  woman 
would,  during  the  rigor,  shake  the  entire  room  and  cause  the  small, 
wooden  h(,..se  in  which  she  li\i;d  to  vibrate.  It  may  be  represented, 
however,  only  by  a  sensation  of  cold,  a  creeping  chill,  in  contra-dis- 
tinction  to  a  shaking  one.  The  fever  rises  suddenly,  and,  as  shown 
in  the  chart,  may  reach  from  103°  to  105°.  At  first  dry  and  pungent, 
the  skin  gradually  becomes  moist,  and  usually  within  from  two  to  five 
hours  of  the  commencement  of  the  rigor  the  patient  is  bathed  in  per- 
spiration. The  entire  dui-ation  of  the  fever  is  from  six  to  twelve 
hours ;  rai'cly  does  it  [R'rsist  for  an  <!ntire  day.  Defervescence  takes 
place  rapidly  when  the  sweating  begins.  Although  the  rule  is  fi)r  the 
paroxysms  to  present  the  usual  stages,  as  here  d(«cril)(xl,  there  were 
in  each  of  the  cases  lesser  attacks,  often  of  fever  alone  oi-  of  fever 
with  sweating.  Slight  rises  of  temperature  without  chills  are  indi- 
cated ill  the  temperature  chart.  Sweating  was  occasionally  seen  without 
the  fever.  In  Case  III,  in  particular,  local  and  general  sweating  was 
much  complained  of.  The  paroxysms  occur  at  irregular  intervals,  but 
I  have  seen  them  recur  daily  for  a  week  or  ten  days.  They  may  pre- 
sent a  tertian  or  a  (juartan  type,  and  in  such  eases  the  diagnosis  of 
ordinary  ague  may  be  made.  In  Case  III,  the  paroxysms  recurred 
for  weeks  on  Friday. 

Third  :  Pain  of  some  sort  is  as  a  rule  present.  It  may,  but  cer- 
tainly does  not  always,  precede  the  rigor.  In  some  cases  it  is  not  at 
all  a  striking  feature,  and  the  most  intense  paroxysms  may  be  quite 
painless  or  only  accompanied  by  a  sense  of  gastric  distress.  It  may 
have  all  the  characteristics  of  genuine  hepatic  colic,  agonizing,  griping 
pain  in  the  liver-region,  with  the  associated  symptoms,  feeble  pulse 
and  clammy  skin.  In  several  of  the  cases  the  pain  was  not  at  all  a 
distressing  symptom. 

'  Loc.  cit. 


nor  \vas 


21 

p]    nt        1         T"       '•'■^"'■"*1.^- '-^'-«  its  on.,  the  patient  ...n- 
plxysT  "'■• '  '     "  "  ''  '  '"^''^  ^■"^"•'•''  ^^^">'  -'tiatod  the 

is  Jlloiir?'""  -f  'n  ^  .'"^"'^  ■"  ^'"  '"^"-^"^^  '-»--"  ^'-'  ^^ttaeks 
s  a    on     ,.f  eonsKlera  .le  nnportance.     They  are  often  ^vell  en^uu-h  to 

cs.     Theie  ,s  not  pn,„-o,ss.ve  deterioration  of  health  and  stren.^th, 
s^idi  a.  we  nuMl  .-.th  .„  ,,ah-,n,ant  .lisease.     With  the  excvntion  of 

2d  i;"t.  'V  7"  '^"^^'"'  ^^•''"  ^^^^^  '—Jaundiced,  she 

yeai.s,  had  a  very  fan-  hiyer  of  pannieulus. 

Regnard '  found  in  <,ne  ..,se  that  the  excretion  of  urea  was  diminished 
dux-.ng  the  attack.  Only  in  Case  IIJ  was  a  careful  studv  of  the  Za 
made  d.u-xng  the  attacks,  hut  no  special  dinn-nut:      was  found 

I)uirj>>os>s.-Th.  s.o.ni(icance  of  hepatic  intermittent  fever  cannot  be 
apprecated  w.thout  takin.  into  account  the  associatcxlgroup  of  symp- 
ton.,  and  whcu  these  are  present  it  points  clearly  to  obstruction  tf 
ho  common  duet  by  calculus.  The  c-ondition  of  the  bile-passa-es  in 
tlH^e  cases  is  one  of  catarrhal,  not  suppun.tive,  cholangitis.  '"  '  ' 
Chrom,.  obstruction  of  the  bile-duct,  eidier  bv  stenosis  or  bv  .rall- 
^oues,  nmy  persist  for  months  . -hout  inducing  this  intermittent 
pyrexia,  as  illustrated  by  tiie  follnN\Ing  cases : 

Gallstone.,  in  the  common  di,cf.      Chronic  jaundice.     No  fever. 

A  man  aged  77,  was  admitted  to  Dr.  Curtin's  ward  h.  the  Phila- 
delplna  Hospital  suffering  with  Jaundice.  He  was  a  Meaver  by  trade 
an<l  a  moderaie  drinker.  He  had  bad  jaundice  on  two  previous  occa- 
sions and  ha<l  been  ,n  the  out-ward  for  several  months,  having  been 
.^1nn,hced  for  nearly  a  year.  Careful  iucp.iry  fron,  the  attendants,  and 
from  the  man  who  occupied  the  next  bed,  failed  to  elicit  anv  history 
of  olulls  or  sweating.     AVhen  admitted  to  the  hospital  he  had  profuse 


irrhoja;  the  a!)doi 
in  the  i)eritonenm  ;  I 


icn  was  distended,  and  evidentlv  tl 


lie 


was  extremely  feeble;  the  stools 


lere  was  fluid 


\vere  sr 


grey 


'  Quoted  by  Charcot,  loc. 


cu. 


f 

1 

if 

fl 

If 

\ 

i 

»  , 

i 

1 

! 

!. 

1 

> 

?  ; 

• 

1 

22 

and  tho  urine  high-colorod  and  contained  bile-pigment,     He  diol  on 
the  fifth  day  after  his  admission. 

I  made  a  disseetion  with  Dr.  Atk>e,  and  tlie  followinij  conditions  w  ore 
found:  Deeply  jaundiced  ;  moderate  ascites  ;  liver  small,. surtiice  granu- 
lar; gall-1  )laddersli'/!  1 1  iy  distended,  ])rojectin;.'()nein(!h  (2.5  cm.)  beyond 
the  liver  margin  ;  tlie  common,  iiepatic  and  cystic  duets  were  greatly 
dilated.  When  the  duodenum  wi:-  opened,  a  ncxliilar  body  projected 
beneath  the  mucous  nictnl)rane  a!>o\i'  the  bile  pii|nll;i.  This  could  be 
felt  as  a  hard  body  witliin  the  iiead  (,i  !l,e  j)an-  reas,  and  Wiis  at  first 
thought  to  be  a  cnm^erons  mass-.  A  probe  was  passed  through  into 
the  ififiee  of  the  duet,  and  on  squee/ing  above  the  pancreas  a  bile- 
gained  mucus  flowed  from  the  orifice.  The  iKxlular  mass  proved  to 
be  a  gaiistone  the  size  of  n  cherry  firndy  imjiacted  into  the  ampulla 
of  Vater.  It  could  neitiier  he  puslied  into  the  common  duct  nor  into 
the  dnodenuiFi.  .V  second  stone  the  size  of  an  oli^'e  was  free  in  the 
duct,  in  whicli  it  could  be  moved  u])  and  down.  The  common  duct 
admitted  the  index  finger,  and  its  main  branches  in  the  liver  admitted 
the  little  finger.  Tlie  gall-l)ladder  was  moderately  dilated  ;  contained 
no  stones  ;  the  cystic  duct  was  free.  Tlu;  i)lad(lei'  and  ducts  contained 
a  bile-stained  mucus.  The  liver  presented  the  appearance  of  ordi- 
nary cirrlfosis.     The  kidneys  were  swollen  and  bile-stained. 

That  stenosis  of  the  common  duet  may  ])ersist  fi)r  months,  or  years, 
without  inducing  chills  and  fever,  is  illustrated  by  the  following  ease: 

Stenosis  of  the  fommnn  dnct.     Jtuinilice  of  fourteen  moiit/is  duration. 
No  fever. 

Hannah  C,  aged  85,  admitted  to  the  Montreal  General  Hospital, 
September  25th,  1880,  with  obstructive  jaundice  of  two  months  dura- 
tion. The  attack  had  followed  diarrhiea,  and  had  come  on  without 
any  pain.  She  remained  under  observati  >"  for  nearly  a  }ear.  The 
skin  was  of  olive-green  color;  the  stool' eii'v  colored  ;  the  m-ine  dark 
greenish-brown;  the  liver  appeared  greatly  enlarged,  the  dullness  in 
the  middle  line  (extending  fi)iu"  inches  (10.2  em.)  from  the  xiphoid 
cartilage,  four  and  one-half  (11.5  cm.)  inches  from  (he  sixth  inter- 
space, and  foiu-  inches  (10.2  cm.)  from  the  seventh  inters])ace  in 
axillary  line.  She  had  frequent  severe  headaches  and  occasional 
attacks  of  pain,  associated  usually  with  vomiting, 


[e  died  on 

itions  were 
facegmuu- 
m.)  beyond 
?rG  greatly 

V  projected 
is  could  be 
■as  at  first 
rough  into 
•eas  a  bile- 
proved  to 

e  ampulla 
let  nor  into 
ree  in  the 
inion  du(!t 

V  admitted 
contained 

<  contained 
■e  of  ordi- 


i,  or  yoai's, 
iving  case : 

duration. 


Hospital, 
nths  dura- 
>n  without 
ear.  '^Phe 
urine  dark 
lulhicss  in 
le  xiphoid 
xth  inter- 
ers})ae(>  in 
occasional 


23 

The  ten.perature  record,  which  extended  ovct  the  entire  period  of 
.     .ay,  occasionally  showed  an  elevation  <,f  two  or  tluv,   decrees 
.u   she  never  had  chills.     The  liver  increased  in  size,  an<l  on  May 
JUe  (III;  note  wasas  lolluws: 

"Till!  livn-  |,„.,  s.,,„|„„||,  ,,,|,„.„.,^,  „^,.,  .J  ^^__^^. 

he  fli,  k  nea,.!,.  ,„  ,|,    „,.,„  ,„■  „„.  ;,;„„,„     ,,,^  ^|.^,^,  ,^^ 
I N«l,  of  gradual  asthenia. 

l»^V..s./._Tlu.re  was  moderate  en.aciation.    The  liver  was  cuhuv-cd 
but^not  so  much  as  was  exp<.,.ted,  owing  to  its  vertical  position      The 
|-fo.'o  was  s,nooth  and  of  a  <lecp  olivc-g^en  coh.r.   S^hc  connnon 
k-duct  was  pervious  to  a  small  probe,  but  the  first  inc-h  and  one- 
h  If  f^^omt,,e  or, (Kv  ,  was  extreuH>ly  narrow,  th.Mvall  da^^ 
and    he  Innng  membrane  rough.     Above  this  part   the   <  uct  was 
g.-e.Hy  d,  Ucd  ..1  the  walls  thickened.     The  gall-bladder  Z^21 
elatel^  d,st<.,ded  ;  the  walls  wore  hypcrtrophi.,1,  and  the  lini„<Muem- 
brane  rough  and  shaggy.     It  contained  three  small   stone,:     The 
hopat.c  duct  and   the  branches  in  the  liver  of  the  first,  second  and 
nrd  d,meusK,ns  were  enormouslv  distended,  forming  elongated  sac- 
cu.l.       I  h.  clu<.t  passmg  to  the  right  h.be  adnu'tted  three  fingers  with 
the  thumb  between  then,.     The  lining  .nemb.ane  of  the  diluted  pas- 
sages Mas  smooth,  not  ulcerated,  not  thickened.     The  dilatation  was 
e.nh,,ed  entnvly  to  the  b,-anchcs  above  named,  the  tcninal  b.-auches 
be.ng  ht  h,  ,f  at  all,  affected.     Thc-e  wcv  n„  dilated  ducts  to  be  s..en 
beneath  the  cap-ule.     The  contents  of  the  duct  au.l  of  the  .-all  bkldcr 
cons^ted  of  dear  mucoi.l  fh.id.     The  tissue  of  the  liver  Mas  smooth 
and  the  ae,n,  m-cII  niarked.     Thee  were  no  cirdiotic  chan-ns 

i  hese  i,|stanees  show  that  it  is  not  the  obstn.ction  alone\vhi,.h  in- 
duces th.  ,ntermitte.it  fever;  the.e  mu>t  be  somethino.  supen„lded, 
probab  y  t^lie  fe,-me„t-pro<lucing  agents,  the  micro-orga.nsms,  which 
as  we  shall  see,  have  been  fbund  in  tM'o  eases. 

From  a  p,-actical  standpoint  su,,p,n-ative  cholanuitis  is  the  only 
aifectmn  from  whi,-h  gallstones  with  hepatic  intermittent  fl^vcr  is  to 
be  differentiated.  The  post-mortem  examination  in  cases  I  and  V 
and  uume,-ous  observations  which  !  have  fbund  in  the  litei-atnre,  show 
fonclus.vcly  that  the  intenuiltent  pyrexia  in  these  long-standing  cases 
IS  not  necessarily  associated  with  snppu,.ation  in  the  ducts.  But  un- 
fortunately, suppurative   cholangitis   is  most  frequentlv    caused  by 


ill 

l^^^^l 

;   .rJ^k 

1 1 


f-l 


24 

blockiiio;  of  the  common  duet  with  a  stone;  and  it  is  important  to 
determine  in  a  j-iveii  ease  the  onset  of  sii|)puiation.  In  <leei(h"n<i'  <Iiis, 
stress  may  he  hiid  upon  the  follo\viii<>;  points:—^])  increased  tender- 
ness in  the  hej)atic  rej^ion  with  possibly  enhu'^cment  of  the  j^all- 
bladder,  as  this  is  a  more  common  event  in  snppurative  eliolanjritis 
than  in  simple  obstruction  of  the  duct;  (2)  the  more  frequent 
return  of  the  ])aroxysms,  and  in  some  instiuiees  the  irreuuhu'ly  remit- 
tent eharaeter  of  the  fever;  (:])  the  jaundice  is  not  so  intense  in 
suppiu-ative  cholangitis,  and  we  do  not  see  the  remarkable  deepeniu<>'  in 
color  after  the  paroxysms  ;  and  (4)  the  general  condition  of  the  patient 
in  the  intervals  is  very  different  in  the  two  conditions.  When  suppu- 
ration exists  there  are  rarely  the  ])rol(mged  periods  of  apyrexia,  the 
freedom  from  distress  and  the  general  betterment  which  we  see  in  eases 
of  simple  gallstone  obstruction. 

There  may  be,  however,  the  g;reatest  difficulty  in  deciding,  and, 
after  all,  in  the  question  of  treatment  it  does  not  make  much  difference. 
I  recently  dissected  a  specimen  of  cholangitis  brought  to  me  by  my 
friend  Dr.  Lainc,  of  Media,  l*a.,  \\hich  \\as  removed  from  a  woman, 
aged  70,  Avho  had  had  from  June  until  September,  chills,  fever  and 
sweating,  recurring  at  irregular  intervals,  either  daily,  or  every  third, 
fourth  or  seventh  day.  The  liver  was  tender ;  no  tumor  could  be 
felt;  the  symptoms  were  evidently  pyiemic;,  and  there  was  inflam- 
mation of  the  i-ight  i)arotid  gland.  The  temperature  record,  a  copy 
of  which  Dr.  Laine  gave  me  and  has  kindly  allowed  me  to  reju'o- 
duce  (.seep.  37),  may  be  compared  with  the  one  previously  given.  The 
chills  recurred  more  frequently,  and  the  temperature  is  altogether  more 
irregular  than  in  any  case  of  ordinary  hepatic  intermittent  fever  which 
I  have  seen.  The  auto]>sy  showed  an  abscess  of  the  gall  bladder  with 
sinuses.  The  cystic  duct  was  bloi'kcd  firmly  with  a  calculus,  and 
another  the  size  of  a  cherry  lay  loose  in  the  common  duct,  not  inter- 
rupting the  passage  of  the  bile.  There  wore  two  septic  abscesses  in 
the  lower  lobe  of  the  left  lung,  and  there  was  fresh  endocarditis  of 
the  aoi-tic  valves. 

In  the  chronic  obstruction  which  results  from  the  compression  of  a 
cancerous  mass  either  in  the  head  of  the  pancreas  or  secondary  in  the 
lymph  glands,  there  are  occasionally  rigors,  due  to  catarrhal  or  su])- 
purative  cholangitis,  but  the  sequence  of  the  symptoms  would,  I 
think,  enable  one  to  decide  between  this  condition  and  gallstones. 


25 


iiixn'tant  to 
'cidin^'  this, 
scd  toiulor- 

)f  tlu>    tiilll- 

cliolanji'itis 
•('  Irequent 
litrly  Riniit- 

intcnsc  in 
i'('j)('ninj«'  in 
the  patient 
hen  suppu- 
nrexia,  tlie 
sec  in  eases 

itling,  and, 
1  (hfrerenee. 
me  by  my 
L  a  woman, 

fever  and 
very  third, 
r  eoiild  be 
^as  inflam- 
)rd,  a  copy 
e  to  repro- 
iveu.  The 
ether  more 
ever  which 
iulder  with 
cidiis,  and 

not  intcr- 
bscesses  in 
•carditis  of 

e.^sion  of  a 
lary  in  the 
al  or  su])- 
woidd,  I 
gallstones. 


■<  I 


■hi 


Temperature  Record  of  Dk.  Laine's  Case.     (;.:';<:  -...  ■^) 


iff  '■' 


:     « 


<    ' 


,   i 


^  * 


26 

The  varying  Infonsity  of  the  jaundice  und  the  compnrativelj-  cosy 
■state  of  the  patient  in  the  intervals  between  the  paroxvsms  are  features 
wJiicli  I  have  n..t  met  with,  iior  seen  referred  t..,  in  the  obstruetion  by 
malignant  growths. 

When  the  fact  is  recog^i'zt-d  that  the  lodgnu.nt  of  a  gallstone  in 
tiie  eominnn  <l,iet  may  be  Mssociated  with  pyrexia  of  intermittent  tvpe/ 
a  confusion  of  these  «,;.e.  with  malaria  is  not  likdv  to  occur.     The 
mistake  js,  however,  very  <M.mmonly  made,  and  in  at  least  five  of  the 
eases  here  reported  the  patients  were  supp„s(-d  to  have  chronic  palu- 
dism,  for  which  they  had  taken  quinine  in  large  doses.    The  error  is  a 
pardonable  one  when  the  patient  is  seen  in  the  interval  In^tw.  en  two  par- 
oxysms, with  very  slight  jaimdic-e  and  perhaps  not  more  than  the  lemon- 
tint  of  skill  seen  in  chn.nic  malaria.     Tlie  historv  of  repeated  c'.ilis  is 
very  likely  to  mislead,  and  it  may  reciuire  a  careful  studv  b.^fore  the 
diagnosis  can  be  established.     Tlu"  negative  condition  of  tiie  blood 
m   these  ciises  may  be  very  suggestive,  as  in  eases  V  and  VII,  in 
which  the  absence  of  Laveran's  organisms  led  to  a  revision  of  the 
diagnosis. 

I  have  no  knowledge  of  the  eases  referred  to  l)v  certain  uriters  in 
which  a  calculus  in  the  duct  arouses  hKeut  malarial  in  1  ounces,  and 
the  paroxysm  thus  results  from  the  combination  of  the  two  factors. 

Paf/in/nf/,,.—Thv  ])athology  of  hepatic  intermittent  fever  is  obscure 
Two  views  have  been  advanced.  Charco.  I,elieves  that  i<  is  due  to  • 
the  production  of  a  ferment  in  the  bile  passages,  the  absorption  of 
which  mto  the  blood  excites  the  febrile  paroxvsms.  A  certain  -.  casnre 
of  support  is  lent  to  this  view  by  the  discoverv  in  the  -^  ts  in  n  case  of 
eholangitis,  by  Xetter  and  Martha,'  of  a  bacillus  simi'  o  ■  of  the 
intestinal  organisms. 

_  It  is  not  only  in  suppurative  cholangitis  that  organi>ms  occur  since 
in  case  I,  in  whicL  the  bile-ducts,  as  stated,  contained  a  vellowish 
viscid,  n.m-puruleat  material.  Dr.  Abbott  <liscovered  a  short  pc.inted 
bacillus  which  did  not,  in  cultures  or  general  characters,  appear  to 
correspond  svhh  the  one  described  by  Xetter  and  Martha. 

The  occurrence  of  endocarditis,  a-  noted  bv  these  authors,  is  also 
extremely  suggestive  of  the  action  of  micro-organisms,  and  the  identity 
of  the  organisms  in  the  ducts  and  those  on  the  heart  valves  was  estab- 

'  Archives  <le  Physiologie,  1886. 


n 


27 

lished  l.y  Xctter  iind  Martlm.     Altooitlicr  tlio  view  ofC'Imrcot  ie  one 
whicli  commends  itself  most  strongly  to  my  mind. 

On  the  other  luuid,  >[iirehison  inclines  to  the  belief  that  the  fchrile 
paroxysms  are  due  to  tlie  simple  irritation  of  the  stone,  not  to  a  septi- 
caemia. To  this  view,  Ord  .>ul)S(  libo,'  stating  that  tli.  paroxysm  of 
fever  is  "due  to  local  irritation  of  the  muc  ,-  meml.rane  piupaL^ated 
to  the  central  nervous  system  and  resnlting  in  pyrexia,  mostly  in 
persons  api  to  take  on  {ihrilitv ,  and  partieidarly  in  persons  who  have 
previonsly  had  intermittent  liver." 

It  was  iJudd,  I  think,  who  drew  the  analojry  lietween  hepatic  and 
lu-ethral  fever,  hut  the  analo^xy  to  which  he  referred  is  rather  lietween 
the  rigoi  in  recent  cases  of  renal  and  hepatic  colic  and  in  the  so-called 
catheter  f  ,  r.  Tlicre  !<,  however,  a  renal  intermittent  lever,  closely 
analogons  u>  the  hej»atic  form.  It  may  occur,  first,  in  tnhercular 
pyelitis;  secnn,!,  in  calcnloii>  pyelitis;  and  third,  in  rare  instances  of 
stone  in  the  pelvis,  without  chronic  suppurative  pyelitis.  The  cases 
in  the  last  category  'iit  a  cnrious  analogy  to  hepatic  intermittent 
fever,  dne  to  gallstom.  mikI  without  suppurative  cholangitis.  There 
are  intcns<-  rigors,  the  temperature  rising  to  104°  and  ]0o°,  with 
great  [lain  in  the  renal  region  and  distinct  changes  in  th(>  cliaracter 
of  the  nrine.  In  a  ciise  of  the  kind  which  I  had  an  opportunity  of 
studying  for  several  months,  the  paroxysm-  reenrred  at  intervals  ' 
a  few  weeks  ;  in  each  one  the  urine  hecame  somew  hat  turbid  but  not 
purulent.  Xo  enlargement  (tf  the  kidney  could  be  di'tected,  but 
there  was  decided  .sensitiveness  in  the  left  renal  region.  In  the 
intervals  of  the  attacks,  the  patient  was  perfectly  well  and  the  urine 
became  clear. 

Fn  all  of  these  cases  the  obstruction  is  not  complete,  as  shown  by  the 
present  of  bile  in  the  stools  for  long  periods  at  a  time.  The  associa- 
tion of  till'  chills  and  fever  with  iutensirK'aticm  of  the  jaundice  must 
be  more  than  accidental.  The  two  musi  be  correlated  in  some  way, 
in  all  }i..>l)ability  through  a  transient  impaction  of  the  stone  in  the 
duct.  Such  :i  condition  might  induce  the  chill,  either  through  reflex 
irritation  as  held  l)y  >[urchison,  oi-  by  preventing  the  escape  from  the 
bile  [)assages  of  toxic  ingredients — ferments  [rod  need  by  the  action 
of  micro-organisms — v,  liicli  are  absorbed   into  the  l)lood  instead  of 


'  Loe.  cit. 


i     I 


1  i 

1' 

28 


cscaiiin^r  fivolv  i„t,,  t|„.  |„)„.<'I.     TI 


bv 


ii  gnu  I  Mil  I  increase  in  tl 


le  nil 


ipaetion  is  prolniMy  (.verconio 


TIk 


IxMiit  uhiel.  permits  the  ei.l.iilns  u,  lid!  I,a<lv 


X'  i-is  a  frn/n  until  tlie  duet  is  str.  leiied  to 


Iv  info  a  wider  portio 


prosst.re  may  mwU  snrU  a  ^nid..  that  the  .stone  is  fmved 


''''I>l'<'"<"il    m   ease   [I,  and   v<>ry  likelv  in   (he  „tl 


n. 


iiiit,  as 


reecverv  ton()\v(.d. 


ler  eases   in  which 


I  iMve  e.npl,as.z,..l  snlli<.ie,,tiy  the  important  diaKuosti,-  indieation.s 
affo.dedl.ythehepat.c  intermittent  fevc,  and  a  careful  att<.nfion  to 
tlie  j,ronp  of  syn.pton.s  presente.l  siu.nhl  onabh-  n,s  (,.  .h-termine 
whether,  ,„  a  j,nven  ease,  jrallston.s  ah.np  are  present,  or  whether  Hnp- 
I""'"""'  I'as  snpcrvened,  and  the  important  ,p,e.stion  remains  a.s  to  the 
progiioMs  and  (he  treatment  in  these  eases 

Froc,nmi..-I  have  heen  (brtnnate  in  the  .-ascvs  which  F  have  ,seon 
as  fhree  of  the.n  reeov.-red  ;  on.,  after  a  persistence  of  the  symp-' 
toms  for  three  years.  .[,u]o.i„„.  f,.,„,  t,,„  .....jtv  with  which  recovery 
IS  menfone,]  ,n  the  literatnre,  snch  eases  mnst  be  dee.ned  exceptionaj. 
rhe  o,,,u  ma.,or,ty  of  then  follow  the  conrse  which  is  sketched  in 
tH.  history  of  ca.ses  I  and  VI,  death  resulting  fn.n,  oxhanstion  or 
cfi()fa!mia. 

Treat>nrnL-The  renuirkable  snccess  which  has  recentlv  been  ob- 
^.m.d  by  sn.^e<ms  inclicate  clearly  the  line  of  treatment  which  shonid 
be  followed,  .Md  althon.^h  the  resnlts  of  opening,  the  co.nmon  dnct 
Imve  not  been  so  favorable  as  in  cholecystoton-v,  y,t  thev  are  snffi- 
uent  y  hopeful  to  warrant  the  attempt  in  every  ease,  either  to  push 
the  .stone  into  the  duoden.mi,  to  crush  or  to  <.xtract  it. 

Of  medicinal  .-.-..nts  I  have  not  fomid  anv  of  the  slij,d,test  value 
..ther  m  p,vve„ting  th,.  onset  of  the  p:,roxysn.  or  causi...  the  solution 
or  pn.pulsion  of  the  stone.  Certain  of  the  cases  were  dren<-hed  with 
ol.ve  o.l,  and  most  of  them  had  taken  soda  salts  and  mineral  ^^■aters 
Many  perhaps  all,  of  them  had  taken  q.unine  in  large  doses,  but  it 
IS  qn.te  ineirectual,  either  to  control  or  to  i>revent  the  paroxysms 

I  have  dealt  thus  at  length  with  this  spec-ial  .symptom,  or  rather 
-symp  om-gro.H.,  so  characteri.sti,.  of  obstruction  of  the  coanmon  duet 
by  gallstones,  a.  I  believe  a  ^vider  recognition  of  its  importance  may 
be  the  means  of  saving  valuable  lives  by  timely  surgical  interference. 
tonc(umn>s,-l,  I„  cancer  and  in  eirhosis  a  certain  number  of  ca.ses 
^sent  fever  of  mn.1o....te  grade,  but  scarcely  distinctive  enouirh  to  bo 


pi 


of  value  ill  diagnosi,> 


\y  ((voifome 
.stlMcJicd  to 
ilcr  |)(»rtinii. 
ri'('<l  out,  as 
s   in  uliifli 

iiulications 
ftciition  to 
(Ictomiirie 
icther  Hiij)- 
iH  a.s  lo  tlio 

have  seen, 
tlic  symp- 
1  r('cr»verv 
vx'cptioiuil. 
ketc'lu'd  in 
uistidu  or 


I 


2\) 

2.  Chronic  ol,..trncti..n  ..f  i\w  .•on.n...h  l.ih-.hul  is  oCtrn  ac-om- 
pa.ued  l.yan  internnttont  pyrexia,  asHociatcxI  witl.  a  svn,p'.Mn,-.ioup 
ot  the  j.rcatertt  (liaoimsli..  iniportanee. 

II  This  pyrexia  is  ,iot  usually  the  result  cf  suppuration,  as  has  been 
snpposcd,  but  occurs  with  a  catarrhal  .■holanj;itis. 

1.  That  it  arises  from  the  absorption  ofa  I'cment,  pro.h.ccd  in  the 
ducts  ,8  re.uh.red  highly  pn.bable  by  the  discovery  of  .nicTo-oman- 
.8ms  both  m  the  catarrhal  (Case  J)  and  in  the  suppurative  cholangitis 
(iSetter  and  Martha). 

5    While  recovery  ,uay  follow,  ,.vcn  afhr  months  (Cases  II  and 
Vlll)  or  even  y,.urs  (Case  1 1 1),  a  fatal  c\  cut  is  onlv  too  comm(»n. 
^    6.  A  nxiognition  of  the  importan.-e  of  this  intermittent  pyrexia  and 

Its  associated  symptom-group,  as  diagnostic  of  obstruction  of  the  com- 
mon duct  by  gallsto.tes,  shoul.l,  in  the  present  <-ondition  of  hepatic 
surgery,  lead  to  more  fre.iu.M.t  operative  interference  in  these  cases 


■  been  ob- 
ch  shoidd 
mon  duet 
are  suffi- 
'  to  push 


est  value, 
L^  solution 
■hed  with 
d  waters. 
es,  but  it 
'sms. 
.)V  rather 
non  duct 
ince  may 
rferencc. 
'  of  cases 
igh  to  bo 


U' 


y  r  1  i  f '  ! 


i 


'i    < 


if  a  91 


■.^WS;«a«!K:i*'' 


!1 

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■  - 

: 

li: 

B        f 

, 

^B 

< 

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J 

■  ^^#4;-: 

:  •■* 

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:  ■  f  • '  ■        f 
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t 

'<.■      ■       1 

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C  III 


[From  Thk  Johns  Hopiaus  Hospital  Reports  Vol   II   Nn   ,    x 

^  iimums,  vol.  II,  ^o.  1,  January,  iggo.] 


CASES  OF  POST-FEBRILE  INSANITY. 
By  WILLIAM    OSLER,   M.  D. 
Ono  of  the  m.»t  .list, -Ksing  , incidents  wl.ich  .„„  t;,li,„v  •,„  ,..„t<. 
fi.n,„fox,,o„„.„,,|,.,„.,.,,i„„,|„,,,„f,„^„,„l    ,,^,.         ■       12 

-.:.:...;.  ,.,.i.::,.^::-r::;t:,:r.;::;::i««^^ 

doipi^H'T  ;'''",:'';"'''■ ":  i'""""-"'  ■"■  '■''■> -■'■™'-'  •■'■  '•'"'"- 

.  """.'"■/      ""     '""■    ' '    fi"»l.-"M,.nl;,l    l„.ai„    ,,,„„|i,i„„     vi.- 

Case  I.-P„„,„„,„,- ,.    ,,,,„,  ,,,„,„,,,,„„„  ,„•„,  ,,„.,,  , 

emabinm  md  MiuimiK.  ■^ 

.    ne  20  h   188  I.     Faniilv  l„s„„,.  ,■»  „,„„,     „„  i,,^,,;,^. 

«as  .,  .-„,  H  ,rfh„,.  ,„  ,1,0  „a,..     I„  .M„,.ol,  ,,,  |„„|  „  ,„„.,.,  „„„,.|^  „^ 
p„e„m,„„a,  .1,..  ,,„.valo.,«„.,.  ,•,.„„,  „.l,id,  wa.  slow,  but  at  the  c„    of 


T 


niveraify  ^rp(!;cal  if- 


zine,  Deufiiiber,  1889. 


•Ameri,..an  Journal  of  t..e  Medici.I  Sciences,  Dece 
Medical  News,  1889 


ruber,  1S88. 


hm^ 


i'it 

,    If 

I 

i       l 

I! 


'r  i  m 


I  I 


I  isi 


•»  i  ii 


':} 


\    c 


•< 

1 

5       ;i  .  n 

1 

!'f 

^ 

^ 

ii 


six  weeks  he  was  able  to  be  uj)  and  about.  The  mind  at  tliis  time  was 
perfectly  clear,  and  had  been  so  throughout  the  illness.  About  two 
weeks  after  convalescence  he  was  noticed  to  be  a  little  odd  and  pecu- 
liar; wa.s  low-spirited  and  dei)ressed,  and  began  to  imagine  all  sorts 
of  troubles;  thought  that  he  was  in  serious  financial  ditheulties.  He 
was  never  violent,  simply  melancholic. 

When  seen  the  patient  was  pale,  with  a  sad,  depressed  (>x])ression  of 
face.  He  would  respond  to  ([ucstions,  but  not  promjjtly,  and  speech 
seemed  slow  and  hesitating.  It  was  only  with  dinienlty  that  any 
account  could  be  obtained  fnmi  him,  of  his  feelings.  His  chief  worry 
seems  to  l)e  that  he  has  lost  the  respect  of  his  friends,  and  that  people 
are  plotting  against  him.  His  friends  were  advised  to  kee[)  him  at 
home  carefully  guarded. 

September  21st.  Patient  seen  to-day  by  Dr.  Toulmin.  He  is 
looking,  and  has  been,  much  better,  has  gained  in  weight,  complexion 
is  good  and  expression  is  cheerful.  He  still  has  hallucinations,  and 
thinks  that  he  has  done  something  which  he  shouM  not.  Twice  he 
has  been  violent,  but  was  restrained  without  much  diffit-ulty.  He 
seems  to  be  progressively  improving. 

Case  II. —  Typhoid  fever  ;  severe  attack  with  inueh  deliv'mm.     Mania 
during  convalescence.     Gradual  recovery  after  four  ino)dlin. 

Mary  J.,  aged  28,  seen  with  Dr.  Fussell  on  February  19th,  1888. 
Familv  history  bad  ;  a  sister  died  of  phthisis.     No  mental  troubles. 

The  patient  in  January  had  an  attack  of  mild  typhoid  fever,  in 
which  the  mind  w^as  clear,  the  pulse  not  ab(jve  100,  temperature  not 
above  10;>°  ;  the  rose  spots  \vere  well  marked. 

On  January  29th,  with  the  temperature  101°,  the  pulse  120,  she 
was  delirious  for  the  fii'st  time.  On  the  30th  and  31st  she  was  con- 
stantly talking,  chietly  on  religious  subjects.  She  tried  to  get  out  of 
bed.  :uul  was  full  of  delusions.  Th'-oughout  the  first  week  of  Feb- 
ruaiy,  her  temperature  was  not  above  101°,  but  the  condition  of 
delirium  was  most  intense,  at  times  becoming  quite  maniacal. 

I  saw  her  on  February  16th,  in  the  following  condition  : 

The  temperature  had  l)een  normal  for  at  least  a  week.  She  was 
emaciated,  and  had  a  wild,  anxious  expression.  She  sat  up  in  bed, 
and  could  not  be  induced  to  lie  down.  She  talked  incessantly,  ciiiefly 
upon  religious  subjects.     It  was  with  difficulty  that  she  could  be  kept 


this  time  was 
About  two 
tl  and  pecu- 
g'inc  all  sorts 
iculties.     He 

expression  of 
,  and  speech 
Ity  that  any 
i  ehief  worry 
[]  that  people 
keep  him  at 

mill.  He  is 
,  (tomplexion 
illations,  and 
.  Twice  he 
ffieiiltv.     He 


tan.     3[ania 

>llOllfll>i. 

'  l!)tli,  18S8. 
ital  troubles, 
loid  lever,  in 
iperature  not 

ulse  120,  she 
she  was  con- 
to  get  out  of 
veek  of  Feb- 
condition  of 
iacal. 
in  . 

3k.  She  was 
iat  up  in  bed, 
<antly,  chietly 
could  be  kept 


but  very  „-,,,k.  '  ittuin«l  homo  soiintl  in  mind 

Jn^«,.pt,™b..  .1,0  ,|ie„  „f  .Uat  .,3  stated  t„  .,e  nleeration  of  the 

Richard  F.  a^.od  ;30,  seen  witii  Dr.  Gibb,  November  '^Oth   1888 

hi-b    but  tl.o   i'..  ,  temperature  uas  never  very 

^U^^V    l^'!^.'''  '>^^:-"   ^'^-   and    fbnr  ..oli 
wopk     .-f  .  delinnm,  wlin-h  set  in  earlv  in  the  first 

much  eniacintP,!      Tl  V   '  ^^"^  '''^^  P^'^'  ^»t  not 

deiusi„„s.     He     tl  n,  1.;  '^"^""7       ""  ™  ^"''J"''  '»  <li«"«'t 

"<»■  i,:»  >vi,K  a,:;r' :it;;: ,  tr-  :,;n;r  :;-'";^--'^- 

ln,»noTif>,l       XT  ■  "joiiL  cvtnrs  wiucui  had  never 

te  o,.,S' j:^:.;:.:;;'";,"'-  "-  '^'^^  ''-'^ "-  ^'^ 

distinct  l„-e,l-      T  .  ■"  '"■'*"•  '•"'"I'ti'i"  presented  no 

hi.  .trength,  the  deUH.nn  and  ment^a,  Ir^.f^  ^'ptr™"^-  "' 

As  a  ehild  he  ,va,  aKvay,  healthy.     Ife  is  of  fair  intelligence  and 

-n«;^rdttS  ''t  •  '^  "■"  •*™ '" """  '>■"-'' '--.  Wa- 

uiiy^amiia  attack,     lemperature  never  ro«e  above  10'^°      fi\ 
the  ontset  the  h«.d  sympton.  were  well  marL      h!  critxi  Id 


lii 


i    ': 


. 


whined  a  gmat  doal.  He  did  not  know  his  mother  ;  ho  had  a  dohision 
that  she  was  dead.  The  fever  only  histed  for  two  weeks;  the  rasli 
was  well  nmrkivl  and  there  was  diarrh(ea.  The  mental  symptoms 
persisted  for  nciuly  four  weeks  after  the  temperature  had  fallen  to 
normal. 

In  the  early  part  of  February  he  seemed  to  have  recovered — at  any 
rate  to  iiuve  gotten  rid  of  his  delusions ;  but  his  parents  sought  advice 
as  he  was,  they  said,  a  little  queer. 

Patient  is  n  bright,  well-nourished  lad,  answers  (piestions  rationally 
remembers  all  about  his  illness,  and  in  conversation  nothing  peculiar 
would  be  noticed  except  that  he  hesitates  and  is  slow  in  his  speech. 
His  mother  says  he  is  very  restless,  never  remaining  quiet  for  more 
than  a  few  minutes.  He  is  most  anxious  minded,  and  constantly 
thinks  something  is  going  to  happen  to  his  parents.  He  frequently 
wakens  at  night  and  behaves  strangely.  He  does  not  seem  to  know 
his  father.  His  slow,  halting  speech  is  quite  marked,  and  is  a  feature 
which  has  developed  since  his  illness. 

Physical  examination,  negative.  Heart  normal.  He  cats  well,  and 
has  gained  rapidly  in  weight  and  in  .strength.  A  favorable  prognosis 
was  given,  and  I  heard  in  May  that  he  had  recovered. 

Case  V. —  Ti/phoid  fever,  severe  attack.  Durhuj  cnnrafemnice  derel- 
opment  of  de/nsiom.  PcmHtence  of  mental  i^t/mpfoim  fur  ten  weeks, 
liecoreri/. 

Thomas  D.,  aged  39,  mechanic,  admitted  to  the  Philadelphia  Hos- 
pital December  2yth,  1888. 

He  had  been  off  work  for  nearly  six  weeks,  and  for  nearly  a  month 
of  this  time  had  been  drinking  heavily.  l'\)r  two  weeks  prior  to  his 
admission  he  had  had  fever  and  liad  been  in  bed  a  great  part  of  the 
time,  during  which  he  continued  to  take  nuich  alcohol. 

On  admission  he  was  rational.  Temperature  101  .(i°,  i)ulse  80.  The 
only  noticeable  feature  was  the  excessive  tremor,  which  was  attributed 
to  alcohol,  as  his  general  condition  was  good.  During  the  first  week 
in  hospital  his  temperature  remained  about  102°.  There  were  dis- 
tinct rose  sjiots.  He  had  rambling  delusions  at  night,  and  would 
constantly  ^sttempt  to  get  out  of  l.'cd.  Dn  the  ()tli  and  7th  the  tem- 
perature registered  very  low,  96.8°,  but  did  not  remain  depressed  for 
many  hours.     There  was  marked  tympanitis  on  the  9th  and  10th. 


ad  a  delusion 
k.s ;  the  rash 
111  symptoms 
lad  fallen  to 

erod — at  any 
jought  advice 

ns  rationally 
ling  peculiar 
in  his  speech, 
liet  for  more 
id  constantly 
[e  frecpiently 
;eem  to  know 
id  is  a  feature 

["ats  well,  and 
hie  prognosis 

'esecnce  diTcl- 
Jor  ten  urcks. 

(lelphia  Hos- 

^arly  a  month 
s  prior  to  his 
t  part  of  the 

ulseSO.  The 
ras  attrilmted 
he  lirst  week 
3 re  were  dis- 
t,  and  would 
7tli  the  tem- 
depressed  for 
th  and  10th. 


'H-me  suspu.o„s  a.ul  pn.sented  HKun- dd^  "'•''•      "^ 

ihrough  lohruary  this  co.Hlition    persi.tod.     ][,.  ^vas  v.tv  di  • 
^-'-^  ^^t  ■'■^l'^-     ile  was  very  iivhlo  and  K.oked  d<,.    s  ...      "  J    ^ 

tin/  '"  ""'"  ""'"'"^  .^Htistiu-torv  ,v>,.l,s.       Vt  <,„,. 

p-;'V;":.i;i:;t«:::;:;:::t;Lr;i;;:::^:"';i::^ 

more  readi  v    iiterestcd    -.rwl  ..f  f;,  i        •        ''"^-      '"'"!'••- 

.       HLUM,(i,  .md  at  times  seemed  (,mte  rational       The 

T«-<.  |...i,.t.s  „f  ,,n„.,i,,,l  i„„,,«  „„,,.  I,c  ,„.„ti„„<,l.    Tl„.  ,„-„.„„.sis 

il  ..t  .,11  ,,„,.,,  l,|o,  ,„  ,,,,,,  ,■„,  ,|,„        .        _^j  1^^  . 

«..*  a,,,„„g  ,1,0  bete,-  ,.|a«.s,  wi,,,  „  ,,„,,„,■„,  J,,,,,,,,,^   ,;„,  ' 

n  t,tat,»,,t.     It  ,s  ,„„.,.ost„,5;  ,„  „<,.,„„  i„  ,,,<,.  Ill,  l,mv    uill, 

.•  r™,v.,v  „f  strcgel,  I  i,,,,,,,.,,,,,.,,,  i„  ,„„„a|  ,„„,,■,,,  „„. 

mind  heeomes  stron<rer. 


"% 


:     t| 


III  e  E    1   ^M    it 


J^i^L 


[Fro.„  THK  JO...,  HOP.,,,  „,,,„,,  ,„^„.^^_  ^^,   ^^_  ^^_  ^_  ^^^^^^^_  ^^^^^ 


RARE  FORMS  OF  CARDIAC  THROMBI. 
By  WILLIAM    OSLER,   M.  D. 

V  J'T"\  •;  f  ^  ^T  ^^'"'""  *'"'""^'^^  «f  *•-  f^'ll"-ing  forms  • 

are    omn':       ;■;       "" '    "'''  -'^-^-bocular  ramification.,  whi'ch 

tdcl    r  .      ""■""'"'  '^^""^'^'^^  ^"d  •"  the  apico.  of  the  ven- 

tiicles  in  ca^^es  of  extreme  dilataticn 

Second:   mural  thn>mbi,  usually  laminated,  whieh  occur  in  the 
dd.j^ed  auncles,  particularly  their  apendices,  in  'the  vontrXi    «  ' 
of  hbrous  myocarditis,  and  in  aneurism  of  the  heart. 

m         H  rt  Ma"'  -11  Icnown.     The  i^lyp-like  thrombi  are  very 

The  second  variety,  mural,  laminated  thrombi,  are  not  very  un 
ommon,  and  the  case  here  reported  is  of  interest  chiefly  on  account 
of  the  enormous  size  of  the  thrombus. 

Ball-thro,nbi,  free  in  the  chambers,  are  excessively  rare  only  five 
cases  having  been  recorded.  '       ^ 

Cask  l.-Large  haimr ambus,  free  In  left  auricle;  mitral  stevo^,. 
2^.  S.,  aged  35,  admitted  to  Montreal  General  Hospital,  February 

br^i   whn '  T-  '''?  ^"^  '"'"  "'^^^'  *«  '^^^^^^^^  «f  shortness  of 
bi^ath,  uhich  withm  the  past  three  years  had  become    .-..h  ^yorse 

Two  years  ago  she  had  an  attack  of  acute  rheumatism   .ud  during 
irfxT?!  *'"'"''  '''"  ^^^  ««^^«i«nally  spat  blood.  ^ 

^nJi~'7  '"*i  •'''''^/"  '"'"'^''^  ''^  ''^^'^''  Iiemiplegia,  vith  aphasia 
Speech  returned  ,n  a  few  days,  but  the  hemiplegia  peiisted  for  some 

'Deutsches  Archiv.  fur  klin.  Medicin,  Bd.  xxxvii. 


I  ■ 


r'*" 


■i 
t 


^ii^i 


2 

montlis.  AVitliin  u  year  slie  had  a  swond  attack,  sinco  which  time 
the  paralysis  has  persisted.  When  admitted  tiiere  was  orthopnoea ; 
face  suffused;  no  dropsy;  complete!  riglit  hemiph';iia ;  the  heart's 
action  was  very  irrejjjular ;  \m\sv  112,  rapid  and  feeble;  the  cardiac 
dullness  was  increased  ;  the  apex  heat  was  normal  in  situation. 
There  was  a  hlowiuf-;  systolic  nuu'mur  in  mitral  re<i'iou,  Temperature 
101°.  The  urine  contained  50  per  cent,  of  alhumen.  The  patient 
became  ra))idly  W(»rse;  cyanosis  increased,  and  death  took  place  on 
the  L'Uh. 

Aitfopsif. — Small,  well  nourished  woman;  ecchymoscs  on  liice  and 
extremities.  FFcart  large,  distended  with  l)lood  clots,  those  in  the 
right  chamber  dark  in  coh)r  and  pulpy.  The  left  auri<'l(>  a\  as  greatly 
enlarged,  and  contained  fluid  blo.nt  ;ind  clots.  Amoii^  these  was  a 
ball-thrombus,  ovoid  in  shape,  thr  -'t/o  of  a  small  pullet-egg,  measur- 
ing 8.5x2.0  cms.  It  was  (juitc  a;'uachcd,  and  lay  free  above  the 
mitral  orifice.  It  Avas  firm  and  oifistio  to  the  touch,  and  on  the  sur- 
face greyish  brown  in  color,  and  jn-esented  little  linear  fibrinous  ele- 
vations, but  no  roughened  sp^r  as  if  it  had  been  adherent  to  the  wall. 
It  gave  an  indistinct  sense  of  fluctuation  as  if  central  softening  had  oc- 
curred.' There  were  no  mural  thrombi  in  the  chamber.  The  endo- 
cardium was  opa(pie,  and  the  walls  thickened.  The  right  chambers 
were  greatly  dilated  ;  the  tricuspid  orifice  measured  12  cms.  in  cir- 
cumference. The  auricular  face  of  .the  valve  presented  fresh  vegeta- 
tions, many  of  them  pedunculated.  The  walls  of  the  ventricle  were 
greatly  thickened.  The  mitral  orifice  was  very  narrow,  Just  admitting 
the  tip  of  the  little  finger ;  from  the  auricle  it  looked  like  a  small 
bntton-hole.  At  the  bottom  there  was  a  funnel-shaped  depression. 
The  edges  of  the  orifice  wei'e  thick,  of  cartilaginous  consistence, 
and  were  fringed  with  small  vegetations.  The  chordae  tendineae 
were  short,  particularly  those  from  the  anterior  muscle  which  was 
attached  almost  directly  u])on  the  flaj).  The  left  ventricle  was  small, 
the  walls  over  12  ram.  in  thickness.  The  aortic  valves  were  opaque, 
and  presented  a  row  of  vegetations. 

The  lungs  were  crepitant  throughout.  They  Avere  tough  and 
brownish-red  in  color ;  they  did  not  contain  an  excessive  amount  of 
fluid. 

'  Tlio  specimen  is  preserved  in  the  Museum  of  the  Medical  Faculty,  McGill  Uni- 
versity. 


y,  McGill  Uni- 


3 

I  "0  ojiht  kNii.ey  |.,vs,.nt<.(I  scvrnl  old  ,.i(.afn..s.    I,,  tl,,.  h-0 
capsiilo  wore  spots  cf  „1,|  s„fh.niii^'. 


I'lial 


case>,  and  roio rs  to  a  t  i  ivl       li>  I.  <i>     +•  i  ■  ■ 

IT  11(11(1.      in  hi.tli   ot  Jus  cases  tici'c  \va<   niiti-il 

» ■  "«-"'■,,  2  ,.,„s,  i„  ,ii,,„„.,..,,  „,„  „„„.,.  _,  ,.„         :• 

m„l,,l  ,„„n™|  „  „,, ,|,„„,.  ,^„„^,^,,,^,_^^     ,^ , 

t  :::r:;;"  ::•  ";■ ' -■  ■""";","■  *-"■""■""'■•  '-■"■'"  '»"■"■•■  ■■-••■■' '>' 

„,■'''"■,.";''■''  ,"'T;  ?'""''   '' ""•""""•  '■■'  '■'■|"-rt"l  l.v  .Ma,.|,,„l    i„ 

-- Uv.el,  ,,,„vul«i„„.,  ,,va,„™,  a,„l  ,•„,<.„ ,|„„„,.     j^     /  ^ 

r    '"      ;""  u   '""""     ''''"■•■°  ""^  '"""•'  '"    'l-  'isl"  a       I.  a 

"TH    ■;'"■•  "■"■'■'■.  "-"™'''^  "I"'.  '-"■  tl-  --  of  a  waluuC 
^^'H<  li  lav  al>ovo  tho  tnciispid  orilife 

1.   f.  xon   Iu.(.kl,„..|,,„,s,„  states  that  l.o  hud  first  doscrilKHP'  these 

nnl   V        t      "rr    ;''^  *''?•'"'''  —  -'"'^,  about  the  sixe  of 
snull  waJnuts,  and  Jay  tivr  in  the  hit  auricle. 

TJ.ese  re.na.'kahl,   structures  are,  as  EeeJdiuj,duu,scn  suL-ests  ...lob- 
ular throud,.  detached  tr..n  tl,e  auricular  appendix,  and; bL  too 
argetopasstlu-ougj.  the  narrowed  nn'tral  ollfice,  a.^e  ke  .t      tat^. 
m  the  aune  e,  growing  constantly  l,y  the  accretion  of  fresJ    la^er    of 
fibnn.     It  .s  not  lilcely  tJ.at  they  produce  any  special  syn.ptoml 

(eft  nunde  by  large  hminatcd  thrombm. 

J!r^'  ^:,  ^'■'  '''"*''  ""^'^  ^^'  "'^'"'"^^^^  ^'^  ^'^«  J^>'"^«  Hopkins  Hos- 

d  s toea  '\r"f  "\  '!"'"'. ''^^^'  '''''  "'^'^  ^^^-W^  -^^  -^treme 
uyspnoea.     JMarrie''   '""^^   '■""   '  --'  ^         i  -i  i  ..      , 


when 


and 


young. 


lias  Jiad  five  cliildren,  all  of  whom  died 


'  Loc.  cit. 
'Alge: 


^.neine  Pathologie  des  Krei.slanfs,  Deutsche  Cliirurgie,  Lief,  2  and 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Family  liistory  nc^ative. 

She  does  not  think  that  she  has  had  searlet  fever.  lias  never  had 
acute  riieumatisni.  She  has  iiever  been  a  very  stronjr  woman  ;  has 
had  shortness  of  breath  at  times  for  ten  or  twelve  years.  For  six 
weel<s  the  shortness  of  breath  has  been  worse.  A  week  ago  she 
began  to  have  a  eongh  f(,r  the  first  time.  Slie  has  been  in  bed  for 
eight  days,  and  lier  feet  have  become  swollen.  She  has  had  a  good 
deal  of  vomitintr. 

3Ut.  Present  condition.  Small,  S])are  woman;  color  asliy-grey  ; 
finger  dps  and  lips  blue.  There  is  marked  ortliopnoea.  The  feet 
and  legs  are  swollen,  AMien  admitted  the  pulse  was  scarcely  to  be 
felt  at  the  wrist,  and  she  was  given  two  hyjxxlermics  of  ether  and 
digitalis.  This  morning  the  pulse  can  just  be  felt,  l)ut  cannot  be 
counted.     Respiration  44, 

Heart.  Very  slight  visible  imjMilso,  To  the  hand,  marked  shock, 
especially  in  e]>igastrinm.  There  is  i\n  indistinct  thrill.  Dullness 
extends  from  the  npj)er  border  of  third  rib,  and  to  the  right  is  two 
finger's  breadth  beyond  the  margin  of  sternum. 

On  auscultation,  below  the  nipple  there  is  a  continuous  rapidly 
succeeding  series  of  sounds,  the  first  and  second  not  distinguish- 
able from  each  other,  and  the  long  pause  is  absent.  There  is  no 
murmur.  At  lower  sternum  the  first  soimd  is  distinguishable.  It 
has  a  ringing,  echoing  character.  At  the  base  the  second  sound  can 
be  distinguished  from  the  first,  and  is  loudest  at  left  margin  '>f  ster- 
num. Most  careful  auscultation  fails  to  detect  a  murmur  at  any  of 
the  cardiac  areas. 

She  was  ordered  hypodermics  of  ether  and  tincture  of  digitalis 
every  three  hours.  In  the  evening  she  seemed  somewhat  better,  the 
distress  of  breathing  \vas  not  so  extreme.  There  was  dullness  at 
the  left  base,  as  high  as  the  angle  of  scapula,  \vith  feeble  breathing;. 

S2nd.  The  pulse  can  scarcely  be  felt.  In  the  mitral  area  the  first 
sound  can  be  distinguished  from  the  second,  and  the  diastolic  pause 
is  more  marked,  2'here  is  no  murmur.  The  8ec(»nd  left  at  base  is 
ringing.  On  palpation  the  shock  in  lower  sternum  is  very  marked. 
The  discre{)ancy  between  the  loud,  cdear  ringing  sounds,  with  the 
moderately  forcible  impulse  of  the  heart,  and  the  extremelv  shabbv. 
scarcely  detectable  prjf.c  is  very  marked.  The  urine  is  scanty  and 
uifficult  to  obtain  ;  it  contains  a  trace  of  albumen. 


Has  never  had 
r  woman  ;  has 
cars.  For  six 
week  ago  she 
•een  in  bed  for 
las  had  a  good 

lor  ashy-grey ; 
oea.  The  feet 
scareely  to  be 
s  of  ether  and 
but  cannot  be 

lurkcd  shock, 
ill.  Dullness 
le  right  is  two 

)U()Us  rapidly 
t  distinguish- 
There  in  no 
ruisliable.  It 
)nd  sound  can 
argin  of  ster- 
mur  at  any  of 

c  of  digitalis 
lat  better,  the 
IS  dullness  at 
ble  breathing;. 
1  area  the  first 
liastolic  pause 
loft  at  base  is 
very  marked, 
ids,  with  the 
■moly  shabby, 
is  scanty  and 


till  nigiit  and  (bed  on  the  morning  of  the  '>,3rd 

i^ftaS"  "     " •ition  of  <,nnnuo.,s  dilatadou  of  the 

AutojJ    ly   D,.   We,..,,      ,j„,^i,.,,.^^^   .,,,.vn.oses   <w.    the   skin  • 

fedema  of  tlie  k>us  ;  fi.ce  cvauosed.  "  ' 

I"  peritoneum,  ,ho,.t  {oO  e,-.,  of  ,.l,,,r  yellouish  serum, 
"'ora.v.      Iho   nght  ,>lc.ura   was  evervwliere  adlx-reut  •    tlie   left 

pleura  contaiued  1  ,.>()()  ce.  of  serum  "  ' 

oec'ud:!dbJ'^^'''''"'^^"''r;'"-"'"^-™^ 

occudHl  I,    a  firm,  grey,sh-red  tlu-ombus  Mhi.h  extended  onlv  a  .hort 
.stan..e:ntothel>nuu.h..softheartery.    There  was  well  mark  Jill-own 
■      '-'tiou  of  t  e  organ,  with  desquamative  heart-,,ueun>ouia.     T 
■sn  .stance  was  dry.      r,.  t,.,  ,,,•,  ,,.„,.  „,,  ,„ft  /   J 

p..  «y  artery  w..  eom,>letely  oclndcl  by  a  gr^'isf.  -red,  laluiil!^ 
th.ombas.      I  ho  ,,■,,],„,„„,,  ,,,        ^„„,  ;^^ 

w..e  e.tens.vely  atherouKUous.     The  substance  of  the  left  luu':: 

Jlea,-t^  w^Mghed  1  ii  ,..  (45:IG  gms.)  (due  la,-gely  to  enorn.ous  throm- 
s  n  the  eft  auru-le)  The  left  ventricle  was  not  hypertrophied  or 
at.  1.      1     a,,peare<l  to  be  n,™l  in  si.e,  and  measu..d  9  ems.  in 

d     ;.  fri  ,"""     ""•  '"  ^'''"'^""^^-     ^^''«  ^^«'«  valves  were 

bglUb    luekeued  aloug  the  Hues  of  closure  ;  otherwise  thev  were  nor- 
mal.    Ihe  m.tral  or.fiee  was  extrenu-ly  steu,.sed.    The  segments  were 
-mpletely  aud  finny  united  to  ea,  h  other  everywhere,  ^xee,>t  a  ttl 
aort.c  extreuuty  of  the  orifice,  where  there  was  an  open  ug  m  asur  m 
about  o  mm.  in  diameter,  which  scarc<.ly  admitte<l  a  imaine;:i;::;:f 
ihe  un. ted  segments  were  thickeucHl  and  calcified,  but  the  s.n-face  was 
not  rough,  saving  to  a  little  extent  on  the  auri,.ular  face.     There  were 
no  vegetafons.     The  chordae  tendineae  were  thickened,  and  the  th. 
«f  the  ,,ai„Ilary  .nusc-les  fibroid.     The  left  auricle  was  greatly  en- 
larged, measnru.g  10  cms.  trausversc^ly  au.l  7  cms.  verticallv.     The 
muscle  wall  was  grcj.tly  hy,,crtro,,hied,  n.easuring  0  mm.  in  thick- 
ness.     The  end,H.anlnMn   ^vas  thickened  and  ojuupic.     The  .handn.- 
was  nearly  fi  le<l  with  an  ante-mortem  thrombus,  la.uinated,  ,,artlv 


1  |)a"tl 


V  red 


C) 


ver  a  gi-eater  i)art  of  its  extent  it 


was  firmlv 


1 

I'B 

i    (■ 


6 


1  ! 


im 


ml 


adliomu  to  llic  wall  of  (lie  iiuricilc;  in  otlirr  ])larc'-  it  was  loosclv  ad- 
herent.    The  thrombus  partly  oeeluded  the  nioiitlis  of  the  pulmoiiarv 
veius,  hut  there  wen;  channels  throu<>h  whieii  the  hhnxj  could  How. 
The  thrombus  had  undergone  softening-  in  various  jiarts.     The  peri- 
cardial sin-tlice  of  the  left  auricle  was  thickened  aiid  o|)a(.ue.     The 
right  ventricle  Avas  markedly  hyperti'opliied  and  dilated.     It  was  i) 
cms.  in  length;  the  walls  averaged   7  nun.  in   thiekue.-s.     The   nuis- 
cular  trabeculae  were  thickened,  and  the  tricuspid  orifice  admitted 
readily  four  fingers.     The  segmcMits  of  the  valve  were  normal,  saving 
a  little  dilfnse  libroid  thickening.     The  right  auricle  was  also  nuich 
hypertrophiedand  dilated;  its  walls  measured  in  places  4-5  m.m.  In 
thickness.     The  hypertrophy  was  especially  well  marked  in  thetrab- 
eeulae.     The  cavity  of  this  chamber  was  much  dilated,  measuring  at 
the  longest  about  8  ems.     The  coronary  sinus  was  greatly  dilated. 
The  pulmonar)^ valves  were  normal.    The  i)ulmonary  artery  presented 
several  opacpie  yellow  atheromatous  itatches.     At  its  bifurcation  there 
was  a  parietal  thrombus,  which  became  an  occluding  thrombus  in  the 
vessels  going  to  the  left  lower  and  to  the  right  upjter  lobes,  as  already 
described. 

The  s])leen  weighed  3]  oz.,  (02.14  gms.)  dark-red  in  -  ' 

The  kidneys  presented  patches  of  atr()i)hy  on  tin;  surfiice.  The 
striae  of  the  cortex  were  distinct.  The  consistence  of  the  organs  was 
increased.  The  renal  arteries  were  atheromatous.  The  liver  wei'died 
33  oz.,  (935.5  gms.)  and  was  in  a  condition  of  red  atrophy. 

INIural  thromyi  are  quite  common,  jiartu  .ih.rly  in  the  anricnlar  ap- 
pendices, but  they  arc;  usually  small.  Massive  coagula,  with  exten- 
sion into  the  vessels,  such  as  existed  in  this  case,  are  extrcmelv  i-are, 
and  occur  chieHy  with  mitral  stenosis.  Cases  arc  on  record  in  which 
the  thrond)ns  has  passed  through  the  narrowed  mitral  orifice. 

Clinically  the  case  is  interesting  as  illustrating  the  disappearance  of 
the  murmurs  in  the  last  stage  of  mitral  steno-is,  not  an  uncommon 
event  when  the  left  auricle  becomes  over  distended.  There  were  no 
symptoms  which  could  be  directly  referred  to  the  blocking  of  the 
auricle  with  thrombi,  none  which  we  do  not  meet  with  in  exti'cmo 
grades  of  dilatation  of  this  chand)cr. 


CLW 


[From  TH.  Johns  Hopk.ns  Hospital  Reports,  Vol.  II,  No.  1.  January,  1890.] 


I  111  cxtrc'iiic 


NOTE  ON  EXDOCARDITIS  IN  PHTHISIS. 

By  WILLIAM    OSLER,   M.  D. 

Within  the  past  few  yeans  several  writers  liave  ealled  attention  to 
tlic  fre.|nent  occurrence  of  vcf^etations  on  the  heart  valves  in  phthisis 
The  appearan,-e  of  Dr.  Percy  Kidd's  paper  in  the  St.  liartholomew's 
Hospital  Reports,'  and  the  dissection  of  a  recent  cas.>  sngsosted  a 
review  of  my  post-mortems,  as  I  had  the  impression  that  the  condi- 
tion was  by  no  means  so  common  as  he  had  found  it.  The  follow- 
ing case  presents  ,)oints  of  special  clinical  interest. 

Stella  D  aged  19,  admitted  to  the  Johns  Hopkins  Hospital, 
November  1st,  w.th  c„ugh,  loss  of  flesh  and  high  fever.  Tempera- 
ture on  admission  10,5°.  ^ 

Her  mother  died  ol  consumption.  She  had  alwavs  been  well 
until  her  present  illness  which  began  about  six  months  ago  with 
cough  and  fovcr.  Thn.ugh  the  summer  she  lo^  flesh  and  had  night 
sweats.  She  gave  up  Mork  in  May.  On  admission  the  temperature 
was  lugh  and  she  was  emuc-iated  and  an.emi,..  There  were  c-avernous 
signs  at  both  apices,  most  extensive  at  the  left;  fine  crepitant  rales 
and  moist  sounds  at  bases. 

_  Heart.  Cardiac  pulsation  visible  in  third,  fourth,  fiftli  and  sixth 
interspaces  In  the  third,  fourth  and  fifth,  the  impidse  was  wavy 
At  apex  the  heart  sounds  were  clear.  At  the  pulmonarv  cartilai 
here  wa.  a  short  systolic  murmur,  quite  localized,  not  traiismitted  to 
the  left  and  not  heard  below  fourth  rib.  At  the  aortic  .'artilaoe  the 
sounds  were  clear.  The  patient  had  persistent  high  temperature 
reaching  twice  to  105°.     She  rapidly  failed  and  died  ,m  the  22d 

llie  autopsy  showed  cavities  at  both  apices.  The  left  upper  lol)e 
was  small  and  did  not  cover  the  heart  to  the  usual  extent  There 
were  numerous  groups  of  tubercles  throughout  all  the  lobes  and  many 
areas  of  gelatinous  infiltration. 

'  Vol.  XXIII. 


■I 


II 


19^ 


Mi 


!->' 


I 


G.ykibi 


■^ 


ii  ; 


2 

The  heart  was  large.  The  cavities  contained  fresh  coagula  and  a 
little  fluid  blood.  The  valves  on  the  right  side  were  normal.  The 
mitral  orifice  was  of  medium  size.  The  edges  of  the  auricular  surface 
were  uniformly  studded  with  large,  recent  vegetations,  grayish-white 
in  color,  soft  and  readily  removable.  The  majority  of  them  were 
pedunculated.     The  aortic  valves  were  free. 

There  were  no  infarctions. 

Fresh  frozen  sections  showed : — (1)  marked  proliferation  at  the 
attached  edge  of  the  vegetation ;  (2)  A  finely  granular  substance, 
composing  the  great  part  of  the  granulations, — the  granules  were 
uniform  in  size ;  (3)  Scattered  about  among  them  were  numerous 
large  compound  granular  corpuscles,  some  of  whic-h  were  rounded, 
others  irregular  spindles. 

Bacilli  were  not  found  in  the  stained  sections. 

Clinically  this  case  'ilnstrates  the  well-known  fact  that  a  murmur 
of  maximum  intensity  in  the  2d  and  3d  left  interspaces  may  indi- 
cate mitral  insufficiency,  but  I  do  not  remember  ever  to  have  heard 
one  so  localized  in  these  regions,  and  inaudible  at  the  apex.  I 
regarded  it  as  an  instance  of  the  murmur  so  common  at  the  left 
sternal  margin  in  cases  of  phthisis  and  thought  to  originate  in  the 
pulmonary  artery,  but  the  condition  of  the  valves  would  indicate 
that  it  was  produced  at  the  mitral  orifice. 

In  216  autopsies  on  phthisis  there  were  12  instances  with  fresh 
endocardial  vegetations — mitral  valves,  8 ;  aortic  valves,  3 ;  aortic 
and  mitral,  1.  With  one  exception  the  disease  was  of  the  verrucose 
or.  warty  variety,  and  did  not  produce  any  destruction  of  the  segments. 
The  case  of  the  ulcerative  form  was  in  a  woman  aged  28,  who  was 
admitted  January  8,  1883,  to  the  Montreal  General  Hospital,  under 
Dr.  Molson,  with  well-marked  chronic  phthisis  and  delusional  in- 
sanity. There  was  involvement  of  the  greater  part  of  the  right  lung, 
with  cough,  night-sweats,  and  rapid  emaciation.  There  was  nothing 
in  her  history  to  call  attention  to  cardiac  trouble,  and  the  condition 
found  at  the  autopsy  was  unexpected.  There  were  extensive  ulcera- 
tive changes  o"    he  mitral  valves. 

In  Kidd's  c  ;ies  there  were  twenty-seven  cases  of  endocarditis  in 
five  hundred  ])hthisical  subjects ;  in  thirteen  of  the  simple  warty 
variety,  in  nine  associated  with  sclerotic  changes,  and  in  four  there 
were  chronic  endocardial  changes  alone. 


In  one  instance  the  recent 


aagula  and  a 
ormal.  The 
icular  surface 
;rayish-white 
f  them  were 


•ation  at  the 
ar  substance, 
ranules  were 
re  numerous 
ere  rounded, 


at  a  murmur 
3es  may  indi- 
o  have  heard 
he  apex.  I 
n  at  the  left 
^inate  in  the 
ould  indicate 

!S  with  fresh 
es,  3 ;  aortic 
he  vcrrucose 
the  segments. 

28,  who  was 
(spital,  under 
ehisional  iu- 
le  right  lung, 

was  nothing 
ihe  condition 
usive  ulcera- 


The  tubercle  bacillus  has  been  fo.md  in  these  vegetations  by  several 
observers  (Cornil.  Heller,  Centralbl.  f  Bacterioloje,  1887   1)^1 
may  be  doubted,  in  the  absence  of  the  characteristic  c  anges  aicM 

fortunate      D^^rrTr  *'"'  "^  '^''  *"  ^""^  °«'  «--  -«- 
lortunate.     Dr.  Kidd,  also,  has  not  found  them  in  his  cases. 


idocarditis  in 
simple  warty 
in  four  there 
ice  the  recent 


f  I 


J       M.| 


!  I 


«   '  -H 


CVI 


TUBERCULAR  PJ:RIT0N1TIS. 

GENERAL  rONSIDERATIONS-TUBERCULAR  ABDOMINAL 
TUMORS-CURABILITY. 

By  WILLIAM  OSLER.  M.  D. 

The  progress  of  aMcminal  surgery  during  tlie  past  few  rears  has 
contributed  to  our  knowledge  of  tubercular  peritonitis  in  two  direc- 
tions—first,  in  tcacliing  u.s  with  what  frequency  the  condition  may 
simulate  or  be  associated  with  abdominal  tumor ;  and,  second  in 
demonstrating  the  curability  of  a  certain  proportion  of  the  ciuse  '  To 
a  consideration  of  these  two  asi)ects  of  the  subject  I  j.ropose  to  ..^.  ote 
the  following  paper,  introducing  their  discussion  by  a  brief  summary 
of  certain  of  the  anatomical  and  clinical  features  of  the  disease. 

I. — General  Considerations. 

Anatomically  the  classifications  which  have  been  made  of  tubercu- 
lar peritonitis  are  not  altogether  satisfactory. 

It  is  customary,  and  correct,  to  exclude  the  cases  of  scattered  miliary 
tubercles  in  the  diffuse  infective  disease  and  also  those  (!ases  in  which 
the  peritoneal  surface  of  tubercular  ulcers  is  alone  involved.  Practi- 
cally, the  great  differences  which  we  see,  post-mortem,  in  this  condi- 
tion result  from  the  situation,  the  rate  of  growth  of,  and  the  degree  of 
inflammation  accompanying  the  tubercles,  and  whether  there  is  much 
or  little  exudation— serous,  purulent  or  hemorrhagic.     The  anatomi- 


I     p* 


59 


.  I 


■ml  if 


I  '!;'...• 


-ti 


!i''i 


irt  ' 


ii  t..i 


2 

cal  basis  in  all  ca-ses  is  essentially  the  same,  and  the  variations  which 
we  meet,  though  distinct  and  marked,  are  scarcely  sufficient  to  war- 
rant the  elaborate  subdivisions  of  this  disease  made  by  certain  writers. 
Thus,  Spillmau,'  in  his  excellent  recent  article  on  the  subject,  makes 
the  fi')U()\ving  Hve  divisions:  tuhercuhsr  miUdire  aiyuii ;  tvbercidotte 
ukcreme;  tuhfronloHeJihmisr ;  prlvi-prrKonUe  tubcrmUm ;  fubrrculoae 
p^ntoneo-pleunih:  T  see  no  reason  for  the  fourth  and  Hllh  groups,  if 
we  bear  in  mind  the  frequency  with  which  the  peritoneal  mischief  is 
excited  by  tubal  disease  and  the  liability  <.f  the  pleural  membranes 
to  be  involved  in  the  process.  A  large  proportion  of  the  cases  m  the 
first  three  divisions  would  at  some  period  of  their  evolution  come  m 
the  fourth  or  fifth  group. 

In  reviewing  a  number  of  post-mortems  in  this  disease  we  find  that 
they  fall  naturally  into,  the  first-named  categories  : 

(1)  AcMte  miUnrji  fuh<rculosin,  characterized  by  a  suddeii  onset,  a 
rapid  development,  and  a  serous  or  sero-sanguineous  exudation. 

(2)  Chronic  camms  and  uh-eratimj  tubcrnihrnn,  characterized  by 
larger  tuberculous  growths,  which  tend  to  caseate  and  ulcerate,  lead- 
ing often  to  perforations  between  the  intestinal  coils,  and  a  purulent 
or  sero-purulent  exudate,  often  sacculated. 

(3)  Chronic  fihrn-tuberculoMi^,  in  which  the  process  may  from  the 
oiitset  be  sub-acute,  or  may  represent  the  final  result  of  the  miliary 
form.     There  is  little  or  no  e.vudation  and  the  tubercles  are  hard  and 

pigmented. 

There  exists  the  t;losest  analogy  between  tubei-cle  as  we  see  it  on 
the  peritoneum  and  as  it  occurs  in  the  lung— the  fresh  miliary  erup- 
tion, the  caseous,  ulcerating  masses  and  the  chronic,  fibroid,  pig- 
mented nodules  may  be  studied  with  equal  fiicility  in  either  structure. 

A  few  practical  points  in  the  morbid  anatomy  may  be  mentioned. 
In  manv  cases  the  process  is  entirely  local.  Thus  in  five  of  seventeen 
cases  of"  which  I  have  post-mortem  notes  the  condition  was  confined 
to  the  peritoneum.  Case  VIH  (given  in  another  section)  is  an  excel- 
lent illustration  of  this,  and  it  will  be  noted  also  that  the  mesenteric 
glands  ^vere  not  affected,  lliis  local  character  of  the  disease,  upon 
which  scarcely  sufficient  stress  has  been  laid,  is  an  extremely  impor- 
tant feature,  particularly  in  discussing  the  propriety  of  oj^eration,  as 

» Dictionaire  Encyclop^dique,  Art.  P^ritonites. 


It' 


[>  varlationH  which 
8ufii<ient  to  war- 
by  t-ertuin  writers, 
the  sulycct,  makes 
aiyuc  ;  tiihrrcitloKe 
vuloK*' ;  inhvrculoHe 
md  fifth  groups,  if 
'itoneal  mischief  is 
[)leuml  membranes 
of  the  eases  in  the 
evohition  come  in 

lisease  we  find  that 

a  sudden  onset,  a 
us  exudation. 
(,  charaeterizcd  by 
and  idcerate,  lead- 
tils,  and  a  purulent 

eess  may  from  the 
suit  of  the  miliary 
)ereles  are  hard  and 

rele  as  we  see  it  on 
fresh  miliary  erup- 
ronic,  fibroid,  pig- 
'  ill  either  structure, 
may  he  mentioned, 
in  five  of  seventeen 
ilition  was  confined 
section)  is  an  excel- 
that  the  mesenteric 
)f  the  disease,  upon 
,n  extremely  impor- 
iety  of  oi)eration,  as 


the  (»iitlo(.k  is  mn.'h  more  favorable  in  the  absent'  of  intestinal,  pul- 
monary or  (ubul  coniplicatidus. 

The  Fall..piiin  tubes  arc  oficn  affected,  but  tiie  proportion  given  by 
various  writers  dificrs  very  much.  Of  my  scrip's  in  one  only  „f  tbur 
post-mortems  in  women  were  the  tubes  diseased.  In  seven  of  sixteen 
cases  from  Immernmnii's  clini,. '  these  parts  were  involved,  [t  is  safe 
to  say,  I  tliink  thiil  iu  from  ;5()  t,.  K)  per  cent.  ..t  the  cases  in  woman 
the  tul)es  are  found  affected.  The  process  is  commonlv  .;.,nfincd  to 
the  distal  ends  and  may  be  primary— whicih  is  usual— ..r  is  secondary 
to  the  periton(>al  involvement.  ( ;yn(>coIogists  now  (liagn..s,.  and 
remove  dilated  tubes  with  su.h  facility  that  we  have  numerous  oppor- 
tunities of  studying  primary  tiib<.rciil..sis  of  these  organs.  I  have 
frequently  been  impressed  with  the  wisdimi  of  this  procednivas  a  pn.- 
tcH-tive  measure,  on  seeing  large  caseous  tubes  with  miliarv  nodules  on 
the  peritoneal  surflice,  since  the  danger  of  general  extension  in  such 
cases  is  very  great.  ITegar's  monograph  *  is  a  storehouse  of  interesting 
information  on  this  subject. 

A  third  point,  worthy  of  attention  on  account  ..fits  importance  as 
an  aid  in  diagnosis,  is  the  frequent  involvement  of  the  pleura.  Sev- 
eral of  the  French  writers  on  the  subject  have  dealt  very  fully  with 
this,  notably  Fernet^  and  BouUand,*  and  Spillman,  as  remarked 
above,  inakes  a  special  sub-division  to  include  these  eases.  In 
Boulland's  list  of  eighty-two  cases  there  were  thirty-eight  with  tuber- 
culosis of  the  pleura,  with  or  without  efi'usiim. 

[n  only  three  of  the  seventei  u  post-mortems,  of  which  I  have  notes, 
w  as  thei-c  tuberculous  pleurisy,— a  comparatively  small  projiortion.  In 
the  twenty  autopsi(.'s  in  Mane's  list  there  were  nine  with  pleural 
involvement.  In  twenty-five  of  Bristowe's*  forty-eight  cases,  the 
pleura  was  affected.  It  is  oflen  only  a  dry  ])leurisy,  occurring  most 
frequently  without  pulmonary  affection,  and  due  to  a  direct  extensicm 
through  the  diaphragm.  The  jiericardium  is  also  liable  in  these  cases 
to  be  the  seat  of  an  adhesive  tubercular  inflammation. 

A^f-— Tubercular  ])eritonitis  occurs  at  all  jieriods  of  life.     It  is 
(jommon  in  children,  in  whom  it  is  often  associated  with  intestinal 

'  Uel)er  Peritonealtuberculose,  Hiiue.     Korschach,  1889. 

Hienitaltuberculose  des  Weil.es.    Stuttgart,  1886.'  ^Quoted  by  Boullaad. 

*  Pans  Thesis,  lS8o.  6  Keynold's  System  of  Medicine. 


!'  .  "' 


I  "I . 


m 


\i--r, 


If) 


ami  incseiitcric  flisoaso.  Full  statistics  doalinf;  witli  its  prevalon-i'  in 
iiilimcy  and  cliildiiood,  arc!  not  availalilc  ;  I  am  Hiirc  the  li^nros  which 
foUou,  do  Milt  represent  the  trne  j)ro|M>rti<)n  of  eases  at  tliis  period  of 
life.  It  is  most  common  between  the  ages  of  twenty  and  forty. 
In  old  ajic  it  is  rai'e,  hnt  it  may  oocMir  even  in  advanced  life,  as 
in  ( "as((  XXI  of  my  series,  in  whidi  extensive  disease  exist<'d  in  a 
man  of  oiffhty-two.  In  my  own  eases  the  distiil)iition  has  been  as 
folh»ws  ;  I'ndcr  ten,  'J  eases;  from  ten  to  t\\<'nty,  I  ;  from  twenty  to 
tiiirty,  4  ;  from  thirty  to  forty,  5  ;  from  forly  to  i\i\y,  7  ;  from  fifty 
to  sixty,  1  ;  and  above  eighty,  1.  Adding  to  these,  (l{)  cases  of  Roul- 
land,'  48  cases  of  1 1  fine,*  ."il)  cases  of  Maiirange,^  (in  which  the  age 
was  given),  and  45  eases  of  Fenwick,^  makes  22'2  in  all  ;  and  joining 
these  figures  to  those  of  Brist(»we,  Hilton  Faggeand  Leiu'rt,*  l.'i")  cjuses, 
we  have  a  total  of  .'}r)7.  Thes(!  analyzed  according  to  ages  give,  under 
ten,  27;  between  ten  and  twenty,  75;  from  twenty  to  thirty,  87; 
between  thirty  and  forty,  71  ;  from  forty  to  fifty,  61  ;  from  fifty  to 
sixty,  li) ;  from  sixty  to  seventy,  4  ;  above  seventy,  2. 

Hex. — The  disease  is  certainly  more  prevalent  among  females.  The 
statistics  of  general  hospitals  and  of  average  mediciil  practice  may 
perhaps  show  a  })repondcranee  of  cases  among  males.  This  was  the 
ctuse  in  liristowe's  figures  at  .St.  Thomas'  Iios|>ital,  in  Fagge's  at  (hiy's 
Hospital,  and  Fenwick's  from  the  Lond(»n  Hospital,  while  in  my 
series  of  twenty-one  cases,  f-lfteen  were  males.  But  when  we  go  over 
the  recent  literature  of  the  laparotomies  which  have  been  performed 
in  this  disease,  we  find  the  number  of  females  to  be  largely  in  excess. 
Thus,  if  we  take  the  figures  of  J^oullaud,  Iliine,  Maurange  and  my 
own,  there  are  GO  eases  in  males  and  131  in  females. 

Jiacc. — It  is  stated  that  the  disease  is  more  common  in  the  negro 
than  in  the  white  race.  Several  of  the  leading  j»hysieians  of  this 
city  have  expressed  themselves  strongly  on  this  subject,  particularly 
Dr.  I.  E.  Atkinson  tmd  Dr.  W.  T.  Howard.  Three  of  the  four  cases 
which  have  occurred  at  the  Hospital  have  been  in  coloi'cd  people,  but 

'  Loc.  clt.  2  Loc.  cit. 

'■'  Piirin  Tliesis,  1889.     De  I' Intervention  Chinirgicale  dans  la  P^ritonite  Tubercu- 
leuse. 
*  Lectures  on  some  Obscure  Diseases  of  the  Abdomen.     London,  1889. 
'  Quoted  by  Spillnian,  loc.  cit. 


Ii  its  prevnicii'-*'  in 
'  the  (itriircs  which 
■s  at  this  period  of 
twenty  and  forty. 
ndvaiH'<'d  \ii\',  ivt* 
sense  existed  in  a 
ition  hiis  h(>en  as 
[  ;  from  twenty  to 
fty,  7  ;  from  fitly 
,  (>!•  eases  of  JJoui- 
iii  which  the  aj;e 
II  all  ;  and  joining 
LelxTt,*  i.'io  ciuses, 
:oages  give,  under 
ity  to  thirty,  87  ; 
61  ;  from  fifty  to 
(  ^* 

»ng  females.  The 
Ileal  j)ra(!tiee  may 
es.  This  was  the 
I  Fajrii-o's  at  (Juy's 
tal,  while  in   my 

when  we  go  over 
'^e  been  performed 

largely  in  excess, 
laurange  and  my 
s. 

nion  in  the  netrro 
>hysieians  of  this 
bject,  particularly 
e  of  the  four  eases 
jlored  people,  but 

1  P^ritonite  Tubercu- 
lon,  1889. 


there  are,  so  fhr  as  I  know,  no  figures  which  could  enable  us  u,  arrive 
at  a  d(.t,n.te  op,„,on  as  to  the  relatively  greater  tmp.encv  of  the  dis- 
ease  among  tiieni. 


Cliuii'itlly  it  is  extremely  ditlieult 


tion  of  the  eases  nf  tube rcul 


to  make  a  satisfactory  classifiea- 


!U-  peritonitis,  and  I  shall  1 


!ier«'onIv  refer  to 


r?'"  -^I !"'  '""^"••"^  '"  ^'-  "-le..f  onset  and  «.  peculiar  symptoms 

not,  JUS  a  rule,  very  fully  discussed.  '      ' 

The  process  may  be  completely /aA./  and  the  ...uption  take  place 
so  s  ,wly  and  so  painlessly  that  the  patient  may  not  have  preseuCd  a 

smgle  sy.nptom  of  abdominal  disease.     Th .dition   hal  thus  been 

nut  w.th   .n     he  operation  fi.r  hernia,  and  more  frequently  still  in 

assocumon  w.th  ovarian  tun.ur.      In  thr f  ...y  ..ase;  it  ..,s  found 

acdentally,  and,  so  far  as  could  be  ascertained,  there  had  not  been 
special  symptoms  pointing  to  abdominal  disease.    Thu<  in  ('a.,.  V  '  . 
man  agc^  40,  well  nourished  and  believed  to  be  in  good  healtl/ was 
a  mined  to  t lie  M....treal  Geoend  Hospital  with  stnnl^nlated  1^ 
le.nia.     He  died  e.ghte, n  hours  after  the  operation,  and  extensive 
tubercular  peritonitis  of  the  fibrous  variety    ^^as   fouml.     The  left 
pleura  was  also  involved.    I„  Case  XI/  a  giVl,  ag.l  I  s,  .as  admitt.xi 
to  hospital  with  severe  typh,.id  fever,  of  whic-h  shedied.     Th<.  abdom- 
inal symptoms  were  those  or.linarily  met  with  and  there  was  no  his- 
tory  o    previous  trouble.     The  post-mortem  showed,  in  addition  to 
<"lmrac  eristic    typhoi.l    l.^ions,  an    extensive    tui.ereiilar   peritonitis, 
whu-h  had  taken  its  start  from  the  Fallopian  tubes.     The  l,in..s  were 
not  affiH-ted     Case  XII,'a  healthy  looking,  well-nourished  childT.f  five 
died  of  malignant  diphtheria  after  an  illness  of  a  {^^s■  days.     An  -.cute 
nnliary  tuberculosis  existed  over  the  entire  peritoneum,  which  con- 
tained a  slight  amount  of  serous  and    much    fibrinous  exudation. 
Ihere  were  tubercles  in  the  spleen  but  none  in  the  lun.^s       V  case  at 
present  in  the  Hospital,  in  Dr.  Kelly's  ward,  illustrutel  "this  latency 
m  the  disejise.      Th.^  patient  had  a  large  ovarian  tumor  which  ^v•as 
removed  October  18th.     The  peritoneum  was  found  universally  cov- 
ered with  recent  tubercles  of  various  sizes  which  also  existed  over 
the  surface  of  the  tumor. 

The  literature  contains  very  many  ca.ses  of  this  kind,  so  that  it  is  a 
tair  conclusion  to  regard  the  disease  in  many  instances  as  latent  in  its 
'  Of  the  series  of  21  casea. 


8 


i      ' 


1  1 1 


;  I 


a 


r 


course,  and  it  is  possible  for  the  process  to  go  on  to  healing  without 
having  induced  serious  symptoms. 

The  onset  of  symptoms  may  be  mddeii  so  that  the  diagnosis  of 
enteritis  or  hernia  may  be  made,  A  remarkable  instance  in  which  it 
was  mistaken  for  the  last-named  disease  is  reported  by  Thoman,*  A 
well-nourished  woman,  aged  30,  was  suddenly  seized  with  pain  in  the 
abdomen,  vomiting  and  fever.  The  physician  avIio  saw  her  believed 
the  sym})toms  due  to  a  hernia,  which  he  thought  he  found  and 
reduced.  The  condition  continued  and  in  the  evening  Thoman  was 
called  in.  No  hernia  was  found  externally  but  an  the  al^domon  was 
distended  and  ])ainful  it  was  decided  to  operate.  The  inguinal  ring 
was  found  closed.  In  the  furtlier  c(jurse  of  the  disease,  the  peritonitis 
became  more  marked,  the  ascites  increased  and  death  oct'urred  on  the 
fourteenth  day.  The  post-mortem  showed  extensive  tuberculosis,  both 
layers  of  the  i^eritoneum  being  covered  with  a  recent  eruption.  There 
were  no  tubercles  in  the  lungs  or  pleune.  This  case  is  not  unique, 
as  y'^illmau'  (piotes  another  instance  in  which  the  symptoms  were  so 
urgent  and  deceptive  that  internal  strangulation  was  suspected. 

This  suddenness  of  ouset  is  very  deceptive  and  usually  leads  to  the 
diagnosis  of  a  simple  acute  peritonitis.  The  following  case  which  I 
saw  on  several  occasions  with  Ross  of  INIontreal  illustrates  this 
point  as  well  as  the  importam  c  o^'  the  pleural  symptoms  so  liable  to 
supervene  in  the  course  of  the  disease  : 

Case  I, — Acute  peritonitis;  tympanites;  abdominal  tenderness,  ivith 
loss  of  flesh  and  irregular  fever.  Pleurisy  loith  effusion. 
Tubercles  on  peritoneum,  pleura,  and  parietal  pericardium. 

G,  C,  aged  17,  colored,  was  admitted  to  the  Montreal  General  Hos- 
pital, Januaiy  2.3rd,  1884,  with  an  attack  of  acute  peritonitis  which  had 
begun  suddenly  three  da}s  before.  For  a  year  he  had  had  ii'regularity 
of  the  bowels,  with  occasional  pains,  and  had  lost  flesh.  On  admission, 
temperature  was  104°,  pulse  92,  The  abdomen  was  tympanitic  and 
there  was  pain  on  pressure.  Under  appropriate  treatment  the  pain 
became  less  and  he  improved.  The  temperature  fell  and  be(.'ame  sub- 
febrile,  until  February  1st,  after  which  it  was  very  irregular,  rising 
to  102°,  103°  or  104°  at  night,  becoming  normal  or  even  subnormal 


'  All.  Wiener  Med.  Zeitung,  1887,  page  306. 


Loc.  cit. 


;o  healing  without 

t  the  diagnosis  of 
istance  in  which  it 
.  by  Thoman.^  A 
id  with  pain  in  the 
)  saw  hei'  believed 
;ht  he  found  and 
;ning  Thoman  was 
1  the  abdomen  was 
The  inguinal  ring 
sase,  the  pevitonitis 
th  occurred  on  the 
>  tuberculosis,  both 
t  eruption.  There 
3ase  is  not  unique, 
symptoms  were  so 
IS  susi)ccted. 
sually  leads  to  the 
ving  case  which  I 
il  illustrates  this 
Lj)toms  so  liable  to 


(d  tenderness,  with 
sy  loith  effusion, 
ericardium. 

treal  General  Hos- 
I'itonitis  which  had 
id  had  irregularity 
h.  On  admission, 
as  tympanitic  and 
reatment  the  i)ain 
1  and  became  sub- 
y  irregular,  rising 
)r  even  subnormal 

cit. 


,        -       7      . 

in  the  morning.  Towards  the  end  of  February  there  was  a  retiu-a  of 
the  pam  and  tenderness  in  the  abdomen.  Early  in  March,  s.ous 
of  pleurisy  on  the  left  side  and  a  friction  nun.nur  developed  near  the 
loft  nipple,  thought  to  be  pericardial.  By  the  17th  of  April  there 
was  well-marked  ctiusion  into  the  left  pleura.  The  heart  in'^puls 
vas  felt  to  the  r.ght  of  steruu.n.  The  abdon^cn  became  mor edis! 
tended,  a  httle  hard ;  no  ascites.  On  the  ;JOth,  l.V  litres  of  ser  m 
were  removed  r<Hn  the  left  chest.  By  May  7th,  tlfe  fluid  had  re-a^ 
cumu  ated  and  he  was  again  aspirated.     Death  took  place  on  the  19th 

H.;tST";[   T   '"^  ^:"'^^--^-"  Records  of  Montreal  Gcnerai 

tTne         ^^ ,  ;    "^" '  ^■7-'^^';--     a-  ■  ,ninal  organs  and  c.oils  of  intes- 

ns<iompletelyghu.d  together.    Peruonenn.  studded  with  innumerable 

wlut^h  masses,  the  s.e  of  small  n.arbles.     On  section  thev  were  firm 

andcaseons.Pcncavdnunwasadhcrenttosternumandtherewere  tuber- 
culous nod.des  mrtltrating  the  parietal  layer.  Tlu-  vis,.eral  layer  was 
smooth  ;  no  tubercles.  In  leiV  pleural  cavity  ^2  litres  of  flnid  The 
pleum  was  covered  with  tubercles;  the  lung  was  airless  and  lay  close 
a^mst  t be  spu.e.  There  were  no  tubercles  in  the  substance  of'^-ither 
lung.  I  he  abdonnnal  organs  were  normal.  There  were  vegetations 
on  Che  aortic  valv-es.  ll.e  l>rain  ^vas  normal.  Dr.  Koss,  in  comment- 
nig  on  this  case,'  notes  particniarly  the  abrupt  onset  of  the  a.-nte 
penton.tis,  winch  un.ler  appropriate  treatment  rapidly  disappeared. 

The  disease  may  set  in  with  prono.mced  !;a.frie  syn,pfo>ns  and  sini- 
ulate  ulcer  or  cancer,  as  in  the  following  case  already  published  in 
my  Pathological  Reports,  ^[ontreal  General  Hospital,  1878. 

Case  IL— Acute  tahercdar  infummafion  of  f/>c peritoneum.  Persistent 
f/a.^tne  symptom..  Small  caseous  num  in  left  Um,.  Rinht-sided 
pleurisy.  ' 

J.  McT.,  aged  ;3o.-Had  been  a  soldier  for  twelve  years,  latterly  a 
sador;  admitted  to  Montreal  General  Hospital  in  September   1876 
complaining  of  weaicness,  loss  of  appetite,  and  frequent  attacks  of 
vomiting.     No  albumen  in  urine.     Blood  normal.     Systolic  murmur 
at  apex.     Xo  enlargenuMit  of  abdominal  organs.     Tenderness  on  deep 
pressure  along  right  costal  border  and  ensiform  cartilage.     The  vom 
iting  became  more  marked,  and  he  had  o.msional  attacks  of  diarrhoea. 
'  Canada  Medical  and  Surgical  Journal,  Vol.  xiii. 


,:) 


I  ! 


r   'I 


'iJi 


The  symptoms  pointed,  though  vaguely,  to  disease  of  the  stomach, 
either  round  uh'er  or  cancer.  The  vomiting  was  with  difficuhy  con- 
trolled, and  patient  became  very  weak  and  anaemic,  the  skin  slightly 
icteric.  Pie  gradually  got  so  feeble  that  he  was  unable  to  move  from 
bed,  and  the  vomiting  was  so  persistent  as  to  necessitate  feeding  per 
rectum.  Through  »Ianuary  and  February  the  vomiting  iliminished, 
but  the  patient  wasted  slowly,  and  the  case  was  regarded  as  malig- 
nant (hsease,  involving  perha])s  the  i)eritoneum.  In  the  beginning 
of  May  the  peritonitis  became  acute  and  general,  and  he  died  on  the 
25th,  profoundly  exhausted.  For  some  weeks  before  death  hemor- 
rhages occurred  in  various  parts  of  the  skin. 

AutopHtj. — The  peritoneum,  contained  3  litres  ot  a  turbid,  slightly 
bloody  Huid,  in  which  were  flocculi  of  lymph.  Here  and  there  the 
coils  of  intestines  were  matted  together  by  easily  separable  adhesions. 
The  transverse  colon  and  stomach  wei-e  in  this  way  glued  together ; 
the  former  covered  also  the  anterior  border  of  the  liver.  The  entire 
peritoneum,  except  the  portion  over  the  stomach,  was  of  a  dark  red 
color,  infiltrated,  sodden,  and  readily  stripped  off  from  the  subjacent 
tissues.  Localized  patches  of  lymph  occurred  here  and  there  upon 
it.  The  whole  membrane  presented  a  great  number  of  small  white 
areas,  flat,  not  projecting  above  the  surface,  and  ranging  in  size  from 
a  hemp  seed  to  a  split  pea.  As  a  rule  they  were  isolated,  but  occa- 
sionally groups  were;  seen.  They  existed  in  about  ecpial  numbers 
over  the  intestines,  mesentery,  and  parietal  peritoneum.  Beneath  the 
latter  were  from  eight  to  ten  larger  white  jiatches,  which,  on  section, 
had  a  caseous  appearance,  were  firm  to  the  touch,  not  encapsuliited, 
and  extended  to  the  depth  of  about  four  millimetres.  On  examina- 
tion of  these  small  and  large  white  masses,  they  were  found  to  be 
almosi  entirely  subperitoneal  and  composed  of  aggregations  of  lymphoid 
corpuscles,  a  little  smaller  than  the  colorless  blood  corpuscles,  and 
with  one,  rarely  two,  nuclei.  In  seciions  through  those  on  the  intes- 
tinal wall,  the  corpuscles  were  seen  to  infiltrate  to  some  extent  the 
muscular  coats.     The  mesenteric;  glands  were  but  little  enlarged. 

The  heart  showed  numerous  ecchynioses  on  ])ericardium  ;  the  walls 
were  flabby,  the  muscle  pale ;  very  little  blood  in  the  chambers. 

There  were  2  litres  of  turbid  fluid  in  right  pleural  sac.  Visceral  and 
parietal  layers  congested,  and  covered  with  flakes  of  lymph.  A  few 
cc.  of  fluid  in  left  sac. 


n%i 


■i 


ic  of  tlie  stomach, 
vith  difficulfy  con- 
c,  the  skin  slifjhtly 
able  to  move  from 
;'ssitate  feeding  per 
niting  diminished, 
•egarded  as  nialig- 
lii  the  beginning 
and  lie  died  on  the 
;fore  deatli  hemor- 

t  a  turbid,  slightly 
lere  and  there  the 
jparable  adhesions. 
ay  ghied  together ; 
Uver.  The  entire 
was  of  a  dark  red 
from  the  subjacent 
3re  and  there  upon 
ber  of  small  white 
nging  in  size  from 
isolated,  but  ocea- 
ut  equal  numbers 
3um.  Beneath  the 
which,  on  section, 
,  not  encapsulated, 
res.  On  examina- 
were  found  to  be 
>;ations  of  lymphoid 
od  eor})uscles,  and 
those  on  the  intes- 
3  some  extent  the 
ittle  enlarged. 
?ardium ;  the  walls 
the  chambers, 
sac.  Visceral  and 
3f  lymph.     A  few 


9 

T^left    L   :  ,J    "  "'^""  '""^""^^^  ^  Sood  deal  of  serous  fluid. 

made  up  ofa  small  CO viH-   1    Y  '^^'H^^^  ^^^nvh  on  section  was 

tubercles  i„  dthc- j,-  '"  "'^ '"'«■      I  l«e  were  no  miliary 

Tlie  spleen  wei-lH.riSll  „,„„.  „nait,.r«l. 

enlarged.  ' '     ^  ^^'^^'  "  Stands  were  not 

IV,  .In.  mistake  „as,  I  Wiev:,  Z^:      "'  '"'"""''  ^'^"  '"  ''^ 
Case  III._,1h,„/,.  ,/  ,„,,/,  nbdomiml  dkmsc.  ■  m;,,h,„l  ..„„ 

M.SS  G.,  aged  about  30,  lairly  well  nourished,  seen  in  Oee„l«r 
.;^tJre     Ltlarrl,t^:rs::t^^^^^^^^^ 

'Canadian  Practitioner,  1888. 


I' 


10 


I  i') 


!  ) 


t    I: 


I  ! 


i       .      t 


lui.' 


)!   . 


■ii  J  i 


saw,  showed  an  irrejrular  fevor  range,  not  at  all  characteristic,  the  tem- 
perature sometimes  dropping  to  normal.     After  persisting  for  about 
six  weeks,  these  symptoms  subsided,  the  fever  left,  and  she  got  up 
and  began  to  gain  strength  ;  but  shortness  of  breath  became  a  marked 
feature  and  she  remained  pale  and  developed  a  slight  cough,  and  it 
was  for  these  symptoms  that  I  \vas  consulted.      The  abdonien  was  a 
little  full,  tympanitic,  nowhere  tender,  no  signs  of  any  effusion.     On 
inspection  of  the  chest,  it  was  seen  that  the  right  side  scarcely  moved; 
the  apex  beat  was  far  ->ver  in  the  left  axillary  line.     There  were 
dullness  and  other  signs  of  extensive  exudation  in  the  r.giit  pleura 
Temperature  was  normal.     She  was  aspirated  with  great  relief  and 
two  weeks  later  fluid  was  again  withdrawn.     She  improved  rapidly 
and  by  tlio  middle  of  December,  the  breath  sounds  were  well  heard 
over  tiie  greater  part  of  the  right  lung,  but  percussion  resonance  was 
defective  over  the  lower  half,  and  at  the  base  quite  flat. 

Considering  the  nature  of  the  abdominal  attack,  the  patient's  family 
history  and  the  gradual  onset  of  th.^  pleural  effusion,  there  can  be  but 
little  doubt  that  this  was  a  case  of  tubercular  perit.jnitis,  mistaken  for 

typhoid  fever. 

A.^clte.^  is  a  frequent  symptom  but  it  does  not  as  a  rule  become 
very  marked  ;  thus  Biat,^  in  an  analysis  of  eighty-one  observations, 
found  .mlv  thirteen  instances  with  extensive  ascites.     In  the  acute 
miliary  tuberculosis  with  rapid  exudation  the  effusion  may  be  bloody, 
but  judo-ing  from  the  published  reco"ds  and  from  my  personal  expe- 
rience this  is  not  so  common  as  in  cancer,  though  the  opposite  state- 
ment is  usually  made.     It  has  frequently  bc>en  mistaken  for  the  effu- 
sion in  connection  with  cirrhosis,  of  whicli,  indeed,  it  may  sometimes 
be  a  complication.     It  is  somewhat  remarkable  with  what  frequency 
acute  tuberculosis  of  the  serous  membranes  occurs  in  this  disease. 
Moroux '  'uid  Wagner  '  have  called  attention  to  the  involvement  of  the 
peritoneum,  which  in  mv  experience  is  not  so  often  affected  as  the 
pleura.     I  have  notes  of  six  cases  in  which  acute  tubercular  pleurisy 
occurred  as  a  find  complication  in  cirrhosis. 

Cases  with  extreme  fi/mpanifes  are  also  common.  This  condition, 
the  result  of  impairment  of  the  tone  of  the  muscular  coats,  is  a  very 
constant  feature  in  all  forms  of  the  disease.     There  are  instances  m 

1  Paris  Thesis,  1884.  «  Paris  Thesis.  1883. 

»  Deutsches  Archiv  f.  Klin.  Medicin,  Bd.  xxxiv. 


icteristic,  the  tem- 
rsisting  for  about 
,  and  she  got  up 
became  a  marked 
ght  cough,  aiul  it 
le  abdomen  was  a 
my  effusion.  On 
le  scarcely  moved ; 
line.  There  were 
I  the  riglit  pleura. 
1  great  relief  and 
improved  rapidly 
s  were  well  heard 
sion  resonance  was 
flat. 

ho  patient's  family 
n,  there  can  be  but 
nitis,  mistaken  for 

as  a  rule  become 
,'-one  ()l)servations, 
itcs.     In  the  acute 
ion  may  be  bloody, 
my  personal  expe- 
the  opposite  state- 
staken  for  the  effu- 
,  it  may  sometimes 
ith  what  frequency 
irs  in  this  disease. 
I  involvement  of  the 
ften  affected  as  the 
tubercular  pleurisy 

n.  This  cimdition, 
Lilar  coats,  is  a  very 
ere  are  instances  in 

883. 


11 

^ed  to  Lir'  *"  ""  '"*'"'"'^'  "^^'^''  ''  '■"  ^^^«^  VI'  *^>  be  refer- 

Of  special  symptoms,  I  wish  to  speak  of  two  only ;  one  of  which 
has  not  received  the  attention  it  deserves 

Sub-nonnal  temperatures.-Mmy  writers  refer  to  the  fact  that  the 
temperature  in  tubercular  peritonitis  may  be  normal,  bu  it  lot.  n 
erally  know^  that  the  temperature  may' be  subnormal  we  kf  o." 
month,  at  a  tune.  My  attention  was  called  to  this  fact  about  four  v  J 
ago  by  my  colleague  Dr.  Musscr,  at  the  Philadelphia  Ilospita'Io 
has  made  a  number  of  observations  on  this  point.  In  the  c^e  of 
fibrous   tubercle,  without   much    iuflammaton-   process   o    ZLn 

omi::  "t1  ™"  7'  tf  ^  ^^^^'-  ^"^  -b-'--^  temperatu;  s    :e 
com  non.      Thus,  m  Case  VIl,  to  be  fully  given  under  an othersect^on 
the  temperature  during  the  patient's  entire  stav  in  the  Hospi Hi  was 
subnormafor  a  greater  part  of  the  day.      In  d,e  earlv  rnZ  nlZ 
thermome  er  rarely  indicated  more  than  96°  or  96.5°  /a  g    dual  .t 

tJae  afternoon,  fiie  same  was  noticed  in  a  second  case,  upon  which 
laparotomy  was  performed,  Case  VIII.  During  her  conva lescen  e  for 
days  at  a  time  the  temperature  did  not  once  re^ach  98°rttXin: 
November  28th,  29th,  30th  and  December  1st,  the  temperl  .J 
taken  every  two  hours,  day  and  night.  On  the  29th 'and  30th^ 
ranged  between  97°  and  98°,  but  twice  registered  at  96°.  Thro  '^^ 
out  December  1st,  2d  and  ;3d  it  only  once  reached  98°  •  the  we 
was  between  96°  and  97.5°.  In  the  diagnosis  of  doubtful  setii 
symptom  may  prove  of  great  value. 

In  a  case  of  Sir  Edward  Sieveking's,at  St.  Mary's  Hosnital  Lon 

S  t7lS  itt,'-  ^-  ^TT'  '''  '''-''''  -Pe-nrf  fir  ^MtTh 
21st  to  Ap  d    6th   ranged  from  95.6°  to  96.^°.     Such  references  as 

tmsoccurin  the  litera:ure,but  they  are  by  no  means  comn  on  L  d 
the  fact  IS  not  widely  recognized. 

Fig>aentat!on.-An  in.-rease  in  the  skin  pigment,  partictdarly  on 
the  face,  .s  an  occasional  symptom  in  tuberculosis  of  tie  periton  um 
I  was  specially  described  by  Gucneau  de  Mussy  in  1879,^  but  I  remem: 
W  m  tlie  session  of  1872-73,  that  Sir  Wm.  Jenner  at  UniverUy 
College  Hosp,tal,  pointed  out  this  condition  as  simulating  Addison^ 
^Transactions  of  the  Pathological  Society  of  London,  Vol.  xx, 

LtudeBurlaPignaentationdelaFacedanBlaTuherculoseabdo,nl„aire.PariM879. 


\m 


11  ll    '         I    ! 


^1 


I  u 


12 

disease  in  a  tuse  of  extensive  abdominal  tuberculosis.  It  wa.s  present 
in  a  marked  dej^ree  inCase  VII,andI  have  seen  oueother  instance.  In 
Case  XII  of  Boulland  s  pajKir,  the  symptoms  of  Addison's  disease 
were  pronounced  and,  post-mortem,  tubercles  were  found  in  the  supm- 
renal  capsules  as  well  as  on  the  i)eritoneum.  1  think  the  condi- 
tion may  be  present  when  tiie  tubertdes  are  confined  to  the  perito- 
neum, and  an  increase  in  the  pigmentation  does  not  necessarily  mean 
that  the  adrenals  are  affected. 

II._TiiM()R  Formations  in  TuBKRcrLAU  Peritonitis. 

To  the  occurrence  of  tumor-like  formations  in  tuljercular  peritoni- 
tis we  are  indebted  for  much  of  the  increase  in  our  knowledge  on  this 
subject,  as  the  errors  in  diagnosis  have  shown  the  frequency  with 
which  these  tumors  occur  and  also  how  amenable  the  condition  is  to 
surgical  treatment.  The  question  has  not  been  fully  considered  by 
any  recent  writer,  yet  its  importance  may  be  gathered  from  the  fact 
that  in  96  eases  in  which  laparotomy  was  performed,  in  37  the  diag- 
nosis was  tumor,  ovarian  or  otherwise. 

One  of  the  best  and  most  suggestive,  and  perliaps  the  first,  of  the 
papers  to  deal  with  this  question  was  by  Dr.  W.  T.  Howard,  of  Bal- 
timore.' He  reviewed  the  literature  of  ovarian  disease  with  special 
reference  to  this  point,  and  showed  how  little  attention  had  really 
been  paid  to  it ;  yet,  even  in  1885,  before  laparotomy  had  become  so 
common  for  iMjritonltis,  he  was  able  to  refer  to  several  instances  In 
which  the  mistake  had  been  made  of  confounding  encysted  effusion 
with  ovarian  tumor.  As  he  remarked,  the  standard  works  on  gyne- 
cology did  not  allude  to  the  subjecit,  and  with  the  exception  of  a  brief 
note  in  Kaulich's^  monograpli,  there  was  no  reference  in  general 
medical  literature.  Busey '  had  previously  reported  a  case  in  which 
an  encvsted  peritonitis  simulated  ovarian  cyst,  and  Gardner*  an  in- 
stance "in  which  the  diagnosis  of  a  suppurating  cyst  was  made. 

More  recently  Van  der  Warker*  reported  an  interesting  case  and 
discussed  the  propriety  of  laparotomy  in  tubercular  peritonitis. 

I  Transactions  of  the  American  Gynecological  Society,  1885. 

•Prager  Vierteljahrsschrift,  1871. 

'Gaillard'sMed.  Journal,  May,  1880.     Quoted  by  Howard. 

♦  Canada  Medical  and  Surgical  Journal,  1885. 

*  American  Journal  of  Gynecology,  1887. 


i.  It  was  present 
)ther  instance.  In 
Addison's  disease 
bund  in  the  supm- 
tliink  the  condi- 
iied  to  the  perito- 
t  necessarily  mean 


Peritonitis. 

iilxjrcular  peritoni- 
knowledge  on  this 
lie  frequenLy  with 
the  condition  is  to 
ully  considered  by 
lered  from  the  fact 
cd,  in  37  the  diag- 

ips  the  first,  of  the 
r.  Howard,  of  Bal- 
[isease  with  special 
itcntion  had  really 
jmy  had  become  so 
I'veral  instances  in 
g  encysted  effusion 
H-d  works  on  gyue- 
exception  of  a  brief 
eference  in  general 
•ted  a  case  in  which 
id  Gardner  *  an  in- 
3t  was  made, 
interesting  case  and 
tir  [jeritonitis. 

■d. 


I 


13 

tre^tmenf  of^T'v"'  "^"'^^''''^Ph^  ^"^  I-P^''^  on  th.  operative 
treatment  of  penton.t.s  m  recent  French  and  German  hteratnre  I 

tliege  tunior-like  formations. 

We  may  ro<»g„i»,a„at„„,i™liy,  and  ,«ssil,lv  ,.|i„™lly,  f„„r  ,,n„„« 

{(t.)     Omental  TnmorH. 

On  the  thin  and  delicate  layers  of  ti.e  epiploon  hiher.les  will  be 
found  If  present  at  all  on  the  peritoneum,  but  Jhev  do  not  often   -.n 
large  masses  wh.ch  can  1.  felt  through  the  abdominal  wall      Tl" 
omental     umor  m  connection  with  this  form  of  peritonitis   results 
from  a  s  ow  tulx-n-ular  process  whi.-h  gradually  puckers  and  r 
he  membrane,  nnt.l   it    forms  an  elongated  firm  m,iss  attached  t. 
d.  transverse  colon  lying  athwart  the  up,K.  part  of  the  abdonl 
Tins  eond,t.on,  perfectly  well  recognizc<l  by  c-linicians,  is  in  man^ 
cases  pe,n.I,ar  and  distinctive.     I  eall  to  mind  at  least  four  instZ  s 
m  two  of  winch  the  diagnosis  ^vas  confirmed  post-mortem.     Of  the  e 
wodulnot^-eurinmyown  practice.     In  the  third,  a  man  at  the 
University  Hospital,  Philadelphia,  with  a  tuberculous  history  and 
ymptoms  wh.ch  po.nted  to  gastric  trouble,  the  abdomen  was  mode  ' 
at^ly  distended  j.a.nless,  and  there  lay  across  the  upper  zone  a  ridg  - 
hke  tumor,  readi  y  separated  from  the  liver  and  sjlleen.     It  was  It 
possible  to  exclude  cancer  but  the  diagnosis  leaned  rather  to  tubercu- 
losis,  and  th.s  was  confirmed  ..me  uK.nths  after  on  th,.  death  of  the 
patient  wh.ch  took  pla,.e  outside  the  Hospital.     The  fbu.tb  ca.se  is  of 
interest,  as  it  occurr.^  in  a  man  over  eighty,  who  p.-escnted  simplv  a 
eomhtion  of  general  enfeeblenent  with  n.oderate  wasting  and  slight 
enla.-gement  of  the  abdo,nen.     He,-e,  too,  there  was  an  elotgated  ma 
■n  the  upper  part  of  the  ..nibilical  .-egion,  whi.-h  p.-oved  on  pos 
mortem  to  be  a  solid  omctal  tumor  <.auscd  bv  ch  onic  tuber  dar 
m  ammafon      There  were  no  tubereules  in  the  hn.gs  or  pi.  ^t 
— ase,  wh.eh  .llnsti-ates  also  a  conditio.,  which  is  mo,-e  common 
than  ,s  supposed,  v.z  :  tubercular  infection  in  the  aged 

These  eases  often  occur  without  much  exudation  and  result  from 


f. 

^ 

!'; 

1 

'i't 

:h 

% 

I  \ 

:\i 

1 

R  ■ 


U 

a  slow,  latent  process  which  may  run  itB  conrso  without  exciting 
serious  symptoms.     To  diagnose  this  condition  from  cancer  is  often 
difficult.     A  pronounced  tubercular  histoiy,  subnormal  temperatures 
—which  are  not  T  think  so  common  in  cancer,  and  which  are  sj^ecially 
likely  to  occur  in  these  more  chronic  cases  of  tuberculosis-and  the 
existence  of  disease  in  the  pleuno  or  lungs  are  suggestive  md.cat.ons. 
The  impossibility  of  avoiding  error  is  illustrated  by  a  case  of  Gaird- 
ner's'  in  which  an  omental  tumor  was  thought  to  be  mesenteric.     In 
connection  with  the  subject  this  writer  says  that  "  it  would  be  easy  to 
show  that  in  most  of  the  text  books  the  diagnostic  characters  and 
significance  of  thickening  of  the  great  omentum  have  been  strangely 
overlooked;    although    the   mere    anatomical    fact   has   long   been 
known."  ^     Cases  I  and  IV  in  the  appendix  to  his  lectures  are  of 
special  value  as  indicating  the  gradual  resolution  in  children  of  these 
tubercular  omental  tumors. 

Fagge^calls  attention  to  the  exiitencc  of  a  resonant  percussion 
note  above  the  mass,  which  sometimes  feels  as  if  attached  to,  and 
indeed  has  been  mistaken  for,  the  edge  of  the  liver  roughened  and 
nodular.  This  point  is  of  some  importance  in  the  diagnosis  of  the 
omental  tumor.  It  must  be  remembered,  too,  that  when  the  mass 
lies  close  to,  or  even  upon,  a  distended  colon  firm  percussion  may 
elicit  flat  tympany.  Cro/er  Griffith  *  has  recently  reported  an  inter- 
esting case  in  a  man,  aged  (54,  in  whom  a  tubeirulous  omental  tumor 
complicated  rather  than  simplified  the  diagnosis.  _ 

R  L.  MacDonnell  has  given  me  the  notes  of  the  following 
case  in  which  the  omental  mass  formed  a  prominent  tumor  in  the 
right  iliac  and  lumbar  region— an  unusual  situation. 

Emma  S.,  aged  30,  admitted  to  the  Montreal  General  Hospital, 
April  5th   1887.     A  thin  delicate  woman  with  a  history  of  scarlet 
fever  at  fourteen,  rheumatism  at  seventeen,  followed  by  some  pul- 
monary  trouble.      She   had   always   been  subject   to   constipation 
neuralgia  and  general  indisposition.     Some  years  ago  she  had  a  foot 

''  The  ittness  of  this  criticism  is  appreciated  after  a  perusal  of  Plan's  large  work 
(Turneuis  de  I'ahdome,,  1880,  Ton,e  i)  in  which  he  devotes,  ^^  ^-^'Sis'S 
just  a  half  a  page  to  tubercle  of  the  omentum  and  does  not  even  allude  to  this  most 

rommnn  form  of  tumor.  ,,         .       /-i  ^  u       icca 

'  s  Practice  of  Medicine.  *  University  Medical  Magazine,  October,  1888. 


without  exciting 
n  cancer  is  often 
■mal  temperatures 
.rhich  arc  s|ie('ially 
i-cnlosis — and  the 
cstive  indications. 
7  a  case  of  Gaird- 
e  mesentei'ic.  In 
t  would  be  easy  to 
;ic  cliaracters  and 
ivc  been  strangely 
t  has  long  been 
lis  lectures  are  of 
1  children  of  these 

ssonant  percussion 
f  attached  to,  and 
or  roughened  and 
e  diagnosis  of  the 
at  when  the  mass 
m  percussion  may 
reported  an  inter- 
ous  omental  tumor 

of  the  following 
uent  tumor  in  the 
n. 

General  Hospital, 
I  history  of  scarlet 
wed  by  some  pul- 
3t  to    constipation, 

ago  she  had  a  foot 


111  of  P&in's  large  work 
1,  of  twenty-eight  pages, 
jven  allude  to  this  most 

gazine,  October,  1888. 


amputated  on  account  of  disease  of  the  ankle  joint.  Ab<.ut  three 
weeks  previous  to  admission,  her  present  illness  ho^an  uith  an 
attaek  of  severe  pain  in  the  abdomen.  With  this  sl...  i.ad  vomiting, 
particularly  after  taking  foo,l.  The  l>owels  were  ..hstinatelv  constt 
pate..  On  admission  there  was  severe  al)dominal  pain';  dorsal 
decubitus,  w.th  knees  drawn  up  ;  pulse  small  and  frequent ;  tempera- 
ture  normal ;  t.mgue  heavily  coated  ;  abdomen  distende,!,  no  flu<-tua- 
t.ou,  no  tenderness,  except  in  the  left  lu.nl.ar  region  over  the 
descending  colon.     Hoart  and  lungs  negative. 

May  ard.  The  .'ondition  remaiiK-d  praetieallv  the  same.  Much 
pain  and  tenderness  over  the  ab,lo„ien.  A  har,l  tumor  could  be 
pkmly  felt  ,n  the  right  iliac  and  huubar  n.gions,  lying  .,uite  to  the  right 
of  the  middle  line.  She  was  removed  to  a  ,,rivate  hospital  and  Dr. 
Gardner  performed  laparotomy.  A  large  tubercular  mass  was  found 
•n  the  omentum,  occupying  the  position  above  noted,  in  some  places 
It  vvas  adherent  to  the  intestines.  A  fanval  fistula  resulted  and  she 
died  of  exiiaustion. 

Klebs  •  describes  an  extensive  fibro-caseous  thickening  of  the  peri- 
toneum whieh  in  one  ease  formed  a  dense,  opaque  vellow  mass  a 
hands  breath  in  width  attached  to  the  parietal  layer' and  stretched 
across  the  abdomen  just  below  the  navel.  Such  a  mass  miglit  be 
readily  confounded  with  an  omental  tumor.  Fenwick  savs '  that  the 
thickened  eapsule  of  the  spleen  may  produce  a  tumor-like  body  in 
the  eft  hypochondriac  region.  More  eommon  I  should  think  would 
be  the  tumors  associated  with  thickening  of  the  capsule  of  the  liver 
to  which  he  also  refers.  Here  an  exudation  sa<-culat(.d  between  the 
capsule  of  an  enlarged  liver-and,  as  Striimpell  notes,  this  condition 
IS  not  uneommon  in  tubercular  peritonitis-and  the  anterior  abdom- 
ina   wall  may  produce  a  localized  tumor  of  great  distinctness. 

there  might  possibly  be  in  tubercular  disease  a  cystic  accumulation 
within  the  layers  of  \\x^  great  <mientum.  P6an  «  cites  such  a  case  in 
which  there  was  an  enormous  tumor  in  front  of  the  intestine  con- 
taining a  brownish  semi-purulent  fluid  and  gas,  the  walls  of  which 
were  evidently  fbrined  l>y  the  layers  of  the  omentum.  Obliteration 
of  the  fommen  of  Winslow  by  tumor  or  by  chronic  i^ritonitis  has  been 
followed  by  encysted  hydrops  between  the  epiplooic  layers. 

'  Handbuch  der  Pathologischen  Anatomie,  Berii      '369 
"-^"^  ^^^-  ..cit,p.338. 


!i*:l^ 


16 

(h.)     S(tc<'i(lat<(l  Kriuliidonft. 

Tlieso  ivro  the  most  cominuii,  us  tluy  iirc  undotihtcdlv  tlu"  moat 
puz/liii^  of  the  alxlominiil  tumors  prtKliu'cd  hy  tiilM-rciilous  disciisc; 
so  piizzliiijr,  iiulccd,  that,  as  a  loii«i'  list  of  cases  shows  in  wiiicli  the 
operation  for  ovariatomy  has  been  porfonncd,  the  very  elect  among 
gyna'cologists  may  he  deceived. 

In  these  cases  a  sero-tihrinons  or  pnrnlcnt  exudation  is  conHned 
and  limited  hy  adhesions  formed  between  the  inl<'stinal  coils,  the 
parietal  peritonenm,  the  mesentery  and  the  abdominal  or  the  pelvic 
organs.  What  is  felt  as  tumor  may  be  entirely  Huid  or  it  may  have 
an  irregular  nodular  character  from  the  presence  between  the  (ioils 
of  large  caseous  masses. 

These  saccnlated  tumors,  due  to  tnberelosis,  may,  as  in  other  forms 
of  peritonitis,  be  met  with  in  the  npper,  middle  or  lower  abdominal 
regions.  In  the  upper  zone,  which  includes  the  stomach,  liver  and 
spleen,  encysted  collections  of  fluid  arc  extremely  common.  Thus, 
we  have  the  localized  peritonitis  associated  with  gall  bladder  disease, 
and  with  varions  affections  of  the  stomach  and  of  the  liver  and  spleen. 
The  effusion  in  these  cases  may  be  limited  entirely  to  the  upper 
region  of  the  i)eritoneum.  In  the  tubercular  disease  by  far  the  most 
common  sacculated  exudation  occurs  here  with  peri-hepatitis,  and  as 
in  the  case  of  Emma  G.  (p.  99)  over  the  surface  of  an  enlarged  liver, 
may  lead  to  the  suspicion  of  a  gall-bladder  timior  projecting  below 
the  edge  of  the  ribs.  I  think,  however,  from  an  analysis  of  the 
cases,  that  these  encysted  peritoneal  tumors  are  less  common  in  the 
upper  abdominal  region. 

In  the  middle  zone,  which  includes  the  peritoneal  cavity  from  the 
level  of  the  transverse  meso-colon  to  the  false  pelvis,  and  which 
embraces  the  omentum  and  intestine,  these  encysted  tnmors  are  much 
more  common  and  as  the  record  of  operations  shows  aie  very  fre- 
quently mistaken  for  ovarian  tumor.  In  reviewing  a  list  of  such 
cases,  it  seems  that  they  fall  into  two  divisions,  those  in  which  the 
entire  anterior  portion  of  the  peritoneal  cavity  was  occupied  by  a 
large  collection  of  fluid  and  those  in  which  a  more  limited  sacculated 
exudation  was  found  on  one  or  the  other  side  of  the  abdomen  or  in 
the  middle  line.  The  following  remarkable  case  reported  by 
Gardner,^  of  Montreal,  illustrates  the  former  :— 
'  Canada  Medical  and  Surgical  Journal,  Vol.  xiii. 


17 

A.  IJ.,  HKi^l  23,  nmnarricHl,  was  st-nt  to  hi,,,  l,y  Dr.  |{,«s  for  .xain- 
•a  -n,  us  .hen.  l.a.l  l,,...  n  s..s,.inon  of  p,..^..an<^.  «,.,.  ,.„,dX 
><lH.n.U.a..,>u..,  o,   ,1...  <lut..  a,   wl.id.  tin.  p.vs.n.  aI„lo.ninaI  .  .! 

and    l.a,     ,.apullv  .nnva...l.     Tl...,.,.   uus  pain    in  ti..  ahWoiuen  • 
gon..a     ...alth  an,   stn-n,,!.  had  .l..li.u.d  and  sh.  had  ....om.e  .a.     - 

ted       I  he  .nensen  had  h. nl,...nt  to,-  tl„-oe  months. 

W..,y/o»      Ti..,.  ahdo.n..,,   was   n.„,.h  ..nhi,-.v<l  ;  w,.l!   ......k.-d 

fl...tnat.on  ...  tu-  ant,..ior  an.l  antn-o-ia,....ai  a.^p,-.,;  ui,h  duiin's  ,„ 

inu-ouss.o..  .„  tho«e  an-as.     1„  .h.  flanl.  a..d  'pi,asrrinn.,  ,h, '  ,oue 
noto  was  p.-osont ;  no  ,!,•„,   or  solid  pa,-t  to  U.  Mt  anvwho...     T 
antono,-  aspo.-t  ot  th.  al.don...,,  was  ,p,it.  ....ili.r.,,.     Th;  nto,-„s  ,„ea! 

.su.-.nj,  two  .nchos  was  p,vss.d  upwar.ls  and  fo.-wai-ds.  The  Jati.-nt 
wasadnuttc^totho  (..neral  H<.spital.  wh..„  it  was  fL.n.d  tl  :^^ 
ad  fever  o  a  sephc  ty,>e,  th.  ten.pe,.atnre  runnin.  ve.y  hiol.  , 
he  eent,v  ot  the  anterio,-  part  of  the  abdonnnal  wall  aho.  t  tl.:  navel 
^0  was  .ede.na  and  a  ..l  hh.sh.  The  diagnosis  of  snpp.^^i^^ 
ovanau  eyst  was  ,„ade.  At  the  ope.-ation,  on  ...achinK  the  perito- 
neum ,,o  separation  of  parietal  fVo.n  visceral  layer  eo.dd  he'n.ade 
The  kn,  e  ente,-ed  a  eol  eetion  of  flnid,  passi,.g  thn.n.h  what  seen.ed 

and  „r.jrated       ri,e  gene.-al  eo.idition  improved  for  ten  days      The 
temperat...-e  then  .-ose  and  she  d..veIope<l  a  eongh  with  purulent  expec- 

1  Z  "''^V't  :t'"^^'  ='"^^  ''''^'  «-  -"^«  ^^^^  the  operation. 
Afop^j-{\oH2.,  Post-mo.-ten,  Reeords,  Montreal  General  Hos- 
pital .  Moderately  .Mnaeiate,l  girl.  A  two-ineh  wound  between  the 
navel  and  the  i.ubes  contained  a  di-ainage  tube  which  passed  through 
Douglas  fossa  ,nto  the  vagina.  On  opening  the  c-avity  of  the  .K^ri- 
toneum,  a   arge  .nass  the  si.e  of  a  .nan's  head,  occupied  the  false 

brane  ha  an  inch  m  thickness.  The  transverse  colon,  although 
hrmly  adhe.-ent  upon  the  surface  was  also  bent  upon  the  liver 
Drawing  this  mass  and  the  liver  towards  the  right  side,  a  collecfon 
of  pus  was  found  below  and  by  the  side  of  the  spk>en,  and  another 
small  collection  lay  under  the  left  lobe  of  the  liver.  On  cnreful 
oxam.nation  it  was  found  that  the  anterior  peritoneal  cavity  wa.s  con- 
verted  into  a  suppurating  cyst,  extending  from  the  liver  to  the  pube« 
Ihe  pelvis  wa«  nearly  filled  by  the  globular  mass  referrc<l  to  above 


, 

\.[ 

■ 

i 

i 

18 


<\i 


'^•'  S » 


*!%»  con.siHU'd  of  till  thf  inU>(J(i'''^s  except  the  tnmsverHc  colon,  closely 
mat!  "(1  top;c<licr  hy  rc<'ciit  soft  adliorfioiis,  which  were  Htiuidcd  with 
miliary  tiiln'rclcs.  EvtTvwhere  the  \vidl8  of  the  cyst  appeurctl  older 
than  the  internal  adhesions  and  had  all  the  appcaraiiee  of  unhealthy 
granulating  nienihrane.  The  walls  and  viscera  of  the  true  pelvis 
wen*  cov(!red  with  the  same  nienii»rane. 

The  lun;;s  contained  many  grey  tubercles  l)Ut  no  <'avities.  Both 
lungs  were  universally  adherent. 

The  intestines  were  normal. 

In  this  remarkable  case  the  sac;  occupied  a  large  part  of  the  [HM-i- 
toneal  cavity  and  ])iish(Ki  the  intestine  into  the  pelvis.  It  is  inter- 
esting to  note  the  (cdeina  and  r<'dness  about  the  navel,  at  which  point 
in  these  cases  of  tubercular  {MMitonitis  spontaneous  perforat'ons  some- 
times occur. 

These  large  |)urulent  exudations  sinudating  ovarian  ttmior  are  not 
necessarily  tubercular  but,  a.s  in  the  remarkable  case  described  by 
Dr.  Fiwing  ]\rears,'  may  I'C  puniperal. 

In  a  larger  numlK>r  of  these  cases  the  tumor  is  more  localized  and 
either  lateral  or  central  in  position,  and  it  may  be  quite  impossible 
to  make  a  diagnosis  from  developing  ovarian  tumor.  The  following 
is  a  case  of  the  kind  to  v.liich  additional  interest  is  added  by  the 
gradual  and  complete  disa])pearauce  of  the  tumor. 

Case  IV. — Ilfness  Hitaulaiing  typhoid  fever ;  development  of  an  ab- 
dominal tumor  which  (p-adaalli/  disappeared.  Rapid  puhnonari/ 
iubercidosis. 

Early  in  November,  1884,  T  n-as  consulted  by  a  yoiing  lady  from 
Montreal,  from  whose  statements  and  from  the  a  i<  n  '  <t  r  phy- 
sician, R.  L.  MacDonncll,  the  following  history  was  obtained : 
No  tuberculosis  in  the  family ;  she  had,  though  somewhat  delicate, 
enioyed  average  health.  Early  in  June  she  was  confined  to  bal  with 
a  V  ^over,  thought  to  l)e  typhoid.  The  temperatm-e  ranged  from 
iOO'  ,  ;  2°.  The  abdomen  gradually  became  distended.  By  the 
end  o^  hV]  '.I  was  evident  that  there  was  fluid  in  the  peritoneum. 
Ti;^-  it)'  le-s,  howev :•  .  was  not  movable  but  persisted  in  the  left 
iliac  and  iight  lumbar  regions  when  the  patient  was  turned  on  her 


'  Transactions  of  the  College  of  Physicians,  Pliiladelphia,  1875. 


tTw  colon,  closely 
ere  Mtiulded  with 
8t  a|)jM'iirc<l  older 
iinoo  of  imlicultiiy 
f  tlie  true  ju^Ivis 

10  cavities.     Both 


>  part  of  the  |)eri- 
Ivis.  It  is  intcr- 
('l,at  which  point 
MU'lbrat'ons  some- 

ian  tumor  arc  not 
•asp  descrihed  by 

lorc  localized  and 
quite  impossible 

'.  Th(^  following 
is  added  by  the 


npment  of  an  ab- 
Rapid  puhwnary 

yonn;^  huly  from 
our'  <  t  r  phy- 
T  was  obtained  : 
)mcwhat  delicate, 
» fined  to  bed  with 
;ure  ranged  from 
stended.  By  the 
I  the  peritoneum, 
sisted  in  the  left 
IS  turned  on  her 

76. 


10 

rijrlit  side.     The  urine  bc-ciirae  very  copious  in  amount,  of  low  .iKnifie 
gravity— I OOr,.     Tl,,.  ,,,„.stion  was  discus,se<l  whether  the  patient  had 
not  an  ovarian  tmnor  u  ith  mihl  lyphoi.l  (i-vcr.     Throu«l,out  Auu.ist 
she  improved.     Ti...  al..lonicn  diminisluMl  in  si/,,  un.l  b,.caiMe  irregu- 
lar in  outline.     The  left  sid.  gradually  Ixranic  more  j,ronn-|H.nt     Un 
the  2(;th  of  August.  Mr.  Lawson  Tait  ..xamined  the  patient  ..ml  said 
H»at  the  tumor  migl.t  l„.  one  of  tlir.-,.  things:  tiilK'n-ular  |K'rit..nitis 
parovanuin  cvst  or  a  <-nng.nitaI  subpcritoncMl  cv>t,  working  its  way 
up  in  front  of  the  ululnn.ci,.      ||..  pn.,li,.t,.l  gradual  absorption  and 
m'ommendcd  m.-isinn  aiul  drainage  when  tlw  fluid  iK-caiiic  thi,  kcncd 
Ihn.ughout   Scptcmhcr  she    in,pr.>ved   very   miu-h  and    tl...      .mor 
mined  in  SI...     On  S..pt,,nlK.r  liOth,  Dr.  MacDonnell  .x.te.   tl.at 
beyond  a  doubt  an  cncystc<l  tumor,  an  large  as  an  adiili  head    lay 
on  the  left  side  of  the  abdomen."      I  saw  tl...  patL^nf  on  th,.  lOtI,  of 
November.      The  abdominal  symptoms  had  aImo>t  disappear.^  :,nd 
there  was  lefl  nothing  moiv  than  an  ..l.scnrc  scum,  of  tidiness  and 
thiek<.ning  in  tl...  left  side.      I  .ould  scan-elv  believe  fn.m  the  exai,  - 
illation  that  there  had   [...en  the  large  tumor  des..ri[)cd  and  sketched 
by  Dr.   MacDonnell.     The   lung  symptoms  were   mark..!  and  the 
patient  was  raj.idly  failing.     She  returned  to  her  horn...  and  died  in 
December. 

The  majority  of  the  eases  in  which  encysted  effiisiiais  have  been 
mistaken  for  ovarian  tumor,  have  been  of  this  kind.  The  exudation 
is  sae(-ulat«l  either  between  the  intestinal  coils,  in  ^vhich  case  it  may 
be  deep-seated  and  give  only  a  sense  of  obscure  fluctuation  or,  a>  is 
mc.re  usual,  the  parietal  peritoneum  forms  the  anterior  wall  of  the  sac 
and  the  collection  simulates  an  ovarian  cyst. 

Lastly,  there  are  the  sacculated  exudations  within  the  pelvis  proper 
in  which  case  the  di.^ase  almost  always  starts  from  the  Fallopian 
tubes.  The  t.ibennilar  process  may  l)e  exi-liisively  upon  the  parietal 
peritoneum  and  th<>  .oils  of  intestines  glued  to  the  lateral  walls  may 
shut  off  completely  the  pelvic  from  the  geni'ral  cavity. 

(c.)     Retracted  and  thickened  intestinal  coils. 

The  matting  together  and  thl-kening  of  several  coils  of  the  intes- 
tines may  form  a  mass  of  great  distinctness  and  even  lead  to  the 
diagnosis  of  a  solid  iuiuor.     This  is  most  frequently  met  with  in  the 


20 


^1 


csecal  region.  They  are  not  necessarily  fixed  tumors  but  may  be 
freely  movable  as  in  Case  IV  of  Spaeth's  paper.'  The  following 
case  is  a  good  illusti-ation  : 

Cask  V. — Tumor  in  ric/lif  iliac  rer/ion,  believed  to  he  malifjnant. 
Gradual  loss  of  jlexh  and  drem/th.  Pain  and  diarrhosa.  Tumor 
formed  of  inteMinal  coih  in  ccceal  ree/ion. 

Man  aged  48.  For  twelve  months  he  had  had  pain  in  the  right 
lural)ar  region  and  in  the  right  groin.  Micturition  was  frequent  and 
he  had  occasional  diarrho-a.  He  had  not  passed  blood  in  the  stools, 
and  there  liad  been  neither  obstruction  nor  vomiting.  There  was  a 
well-marked  tumor  in  the  right  iliac  region.  Towards  th<!  end,  a 
cough  with  imico-inirulent  expectoration  developed  and  there  was 
dullness  at  the  base  of  the  right  lung.  During  the  last  three  days  of 
life  the  al)domen  was  tender  and  tympanitic.  The  tumor  was  be- 
lieved to  be  malignant  in  chariicter. 

AutopfijI. — Slight  emaciation.  Abdomen  distended,  oOO  cc.  of  turbid 
fluid,  with  many  flakes  ot  lymph  in  the  peritoneum.  The  coils  of 
the  intestines  were  matted  together,  but  could  be  sejjarated.  A  mass 
of  adlierent  bowel  filled  up  the  right  iliac  fossa  ;  several  of  the  coils 
communicated  with  the  colon,  by  perforations  in  the  terminal  part 
of  the  ileum.  These  coils  and  the  ascending  colon  formed  a  firm 
solid  mass  which  occupied  the  right  iliac  fossa  and  which  had  been 
mistaken  during  life  for  a  tumor. 

AVhen  slit  open  the  lower  two  inches  of  the  ileum  were  found  to  be 
extensively  diseased.  The  walls  were  thickened  and  tlie  mucosa 
ulcerated.  The  caecum  was  much  contracted,  only  admitting  the 
thumb.  The  wall  was  nearly  half  an  inch  in  thickness.  In  the 
upper  part  of  the  ileum  there  was  a  typical  tuberculous  ulcer.  There 
was  general  tul)ercu]ar  peritonitis,  and  the  serous  covering  of  the 
liver  was  greatly  tLIckened. 

The  lungs  presented  small  cavities  at  the  apices  surrounded  by 
fibrous  tissue  and  groups  of  tubercles.  The  lower  lobes  were  normal. 
The  kidneys  presented  a  few  small  tubercles. 

Here  no  doubt  the  starting  point  of  the  trouble  was  in  the  caecum, 
in  whi(!h  the  disease  was  much   more  extensive  and  older  looking 

iDeuUcln;  Mi;d.  Wofhensehrift,  No.  20,  1889. 


21 


nors  but  may  be 
'     The  following 


to  he   malif/nant. 
liart'hoea.     Tumor 

pain  in  the  right 
was  frequent  and 
lood  in  the  stools, 
ng.  There  was  a 
)warcls  tin;  end,  a 
3d  and  th(jre  was 
last  three  days  of 
le  tumor  was  be- 

tl,  500  00.  of  turbid 
im.  The  ooils  of 
parated.  A  mass 
jveral  of  the  coils 
the  terminal  part 
on  formed  a  firm 
1  which  had  been 

I  A\ere  found  to  be 
and  the  mucosa 
ily  admitting  the 
hickness.  In  the 
Ions  ulcer.  There 
5  covering  of  the 

es  surrounded  by 
ol^es  were  normal. 

ivas  in  the  cjecum, 
ind  older  looking 


than  in  any  other  part.  The  solidity  and  firmness  of  these  tumor 
masses  f .  M  by  the  intestinal  coils  are  ver-.-  remarkable  and  as  in 
this  case  are  very  apt  to  lead  to  error  in  diagnosis. 

There  is  another  remarkable  form  of  intestinal  tumor,  the  result 
of  chronic  poritoi;itis,  not  neoessarilv  tubercular.  The  small  intes- 
tine IS  .shortened  by  puckering  and  thickening  of  the  mesentery. 
Ihe  walls  are  enormously  thickened  and  th.>  entire  coil  inav  form  a 
iinn  knot,  lying  do.se  against  the  spine.  WJion  matted  together  l)v 
adhesions  this  coil  of  intestines  may  give  on  examination  the  i.lea  of 
a  solid  mass.  The  foll.nving  is  a  remarkable  instance  of  the  kind  • 
^  Sarah  A.,  aged  82,  admitted  to  the  Philadelphia  Ilosj.ital,  December 
22,  188 ^  with  ascites,  stated  to  be  of  several  months  duration.  At 
first  tiie  effusion  was  nio.kn-ate  but  it  increased  so  that  tapping  was 
necessary.  Abu.it  five  litres  of  a  sero-fib.inous  fiuid  ^^,.■c  removed. 
The  hver  oonld  not  be  f(>lt,  bnt  presented  about  three  inches  of 
vertical  dullness  in  the  nippk^  line. 

The  spleen  was  not  paljiable.     After  withdrawal  of  the  fluid,  a 
rounded,  firm  mass  about  the  siz(,  of  a  cocoanut,  could  be  felt,  and 
seen,  in  the  central  part  of  the  abdomen.     It  was  somewliat  movable 
and  a  little  irregular  on  tlu"  surface.     The  fluid  reacciimulated  and 
she  was  again  tapped  and  an  eqnal  amount  withdrawn.     The  tumor 
was  centrally  placed,  and  so  readily  separated  from  any  of  the  abdom- 
inal viscera  that  I  tiiought  it  very  probably  of  retro-peritoneal  origin. 
The  autopsy,  January  20th,  1888,  showed  tlie  ].eritoneum  cov.^red 
with  flakes  of  moderately  firm  ]ym])]i.     The  tumor  was  seen  to  be 
made  up  of  the  small  intestine  greatly  shortened  and  thickened,  the 
coils  closely  united  with  each  other  forming  a  mass  the  size  of  a  lar-e 
cocoanut,  closely  adlicrcnt  to  the  spine.     It  seemed  scarcelv  credible 
that  the  small  intestine,  even   puckered  and  thit^kened  as   it  was, 
should  form  so  firm  and  so  small  a  mass.     The  mesentery  Mas  very 
greatly  thickened.     TJiere  was  much  pigmentation  of  the  peritoneal 
coat,  the  muscular  >vall  was  greatly  tiii(;kened  and  the  mucous  mem- 
l)rane  of  the  ileum  was  thrown  into  thick  fokls,  resembling  the  val- 
vuhe  eonniventes.     Tlie  transverse  colon  and  sigmoid  flexure  were 
much  contracted.     There  was  thickening  about  the  ai)i)endix  and  in 
the  mucous   membrane  of  the  ciecum  there  were  two  small   ulcers. 
The   liver  presented  senile  atrophy  but  no   (urrhosis.      There  was 
extensive  perihepatitis. 


^  ^', 


A 


22 

The  other  organs  presented  no  special  changes. 

Tubercles  were  not  found,  and  the  case  appears  to  have  been  one  of 
chronic  peritonitis,  starting  possibly  from  the  csecal  region. 

A  very  similar  condition  to  this  has  been  found  in  the  chronic 
tubercular  disease.  Some  years  ago  I  performed  a  post-mortem  for 
Howard,  of  Montreal,  on  a  woman  aged  about  3U,  who  had  signs  of 
chronic  disease  of  the  peritoneum  with  ascites.  On  t)pening  the 
abdomen,  the  entire  cavity  ^vas  converted  into  a  large  fiecal  abscess. 
The  anterior  wall  of  the  ciecum  was  completely  destroyed  by  the 
tubercular  ulceration  and  the  fluid  ftoces  had  passed  directly  into  the 
peritoneal  cavity.  The  small  intestine  formed  a  i)uckered  and  retracted 
coil  which  lay  close  against  the  spine,  forming  a  firm  bunch  which, 
as  in  the  other  case,  presented  a  strange  appearance  in  contrast  to  the 
greatly  distended  peritoneal  cavity. 

Prochownick  '  reports  a  remarkable  case  in  a  girl  of  16,  who  pre- 
sented in  the  right  side  of  the  abdomen  a  hard  somewhat  nodular 
tumor,  which  extended  from  Poupart's  ligament  to  a  point  above  the 
navel.  ^Vt  the  operation  the  mass  \\as  found  to  be  composed  of  the 
entire  intestinal  tract,  from  duodenum  to  the  beginning  of  the  rec- 
tum, united  in  a  single  coil,  closely  matted  together  and  covered  with 
lymphoid  granulations. 

The  coils  may  not  form,  as  in  these  cases,  a  uniform  tumor,  but 
there  may  be  a  separation  into  three  or  four  irregular  masses,  divided 
by  fissures  and  covered  with  thick  lymph. 

It  is  possible  for  the  coil  to  form  a  resonant  tumor  ;  thus  Goodell 
writes  that  "  in  one  of  his  cases  of  tubercular  peritonitis  the  intestines 
were  gathered  up  towards  the  sternum  in  a  bag  of  false  membrane, 
making  a  well-defined  resonant  tumor,  which  was  very  puzzling  until 
the  abdominal  cavity  was  opened."^ 

(<J.)     Mesenteric,  G lands. 

Less  common,  perhaps,  in  tubercular  peritonitis  than  any  one  of 
the  previous  conditions  is  the  presence  of  tumors  caused  by  enlarged 
glands.  So  far  as  I  can  ascertain,  in  none  of  tiie  cases  of  laparotomy 
did  they  lead  to  an  error  in  diagnosis.     Cases  are,  however,  on  record 

»  Deutsche  Med.  Wochensclirift,  No.  24,  1889. 
■-'Private  letter,  iS'ovember  29th,  1889. 


23 


3  have  been  one  of 
[  region. 

id  in  the  chronic 
L  post-mortem  for 
who  had  signs  of 
On  opening  the 
irge  ftecal  abscess, 
destroyed  by  the 
J  directly  into  the 
;ered  and  retracted 
irm  l)unch  which, 
in  contrast  to  the 

I  of  16,  who  pre- 
ioraewhat  nodidar 
a  point  above  the 

composed  of  the 
nning  of  the  rec- 

and  covered  with 

liform  tumor,  but 
ir  masses,  divided 

or ;  thus  Goodell 

litis  the  intestines 

false  niembrane, 

3ry  puzzling  until 


than  any  one  of 
used  by  enlarged 
SOS  of  laparotomy 
^wever,  on  record 


m  which    extensive   tuberculosis   of  these  glands  formed  jialpable 
tumors,  associated  with  ascites.     One  of  the  most  accuratdv  des^   "-ed 
is  by  Gairdner  : '    A  man,  aged  21,  had  nodular  tumors  "'of  varying 
distinctness,  sometimes  nearly  superHcial,  sometimes  over-lapped  by 
intestines,  not  capable  of  being  idcntifiid  with  anv  of  the  greater 
viscera,  to  a  great  extent  mobile  and  chicHy  Mt  in  the  left  umbilical 
region,  very  dense,  hard,  irregular  and  somewhat  nodulatc,  altogether 
having  much  of  the  position  and  some  of  the  characttcrs  of  mesenteric 
glandular  tumors."     The  post-mortem  showed  these  glands  greatly 
enlarged,  hard,  inelastic  ;  on  section  solid,  no  su])i)urati(.n   Imt  prJ- 
enting  a  yellow  intiltrat«l  matter.    There  was  no  disease  of  the  lungs 
or  of  other  organs,  nor  was  the  pcritcmeum  involved.     One  cannot 
doubt  the  tuberculous  nature  of  this  case.     1  have  not  seen  in  the 
adult  a  similar  one  in  which  the  tuberculosis,  conHncd  to  the  mesen- 
teric  glands,  lu-oduced    large  tumors,  but  I  have   seen  a  ])recisely 
similar  condition  limited  to  the  retro-peritoneal  glands.      (Philadel- 
phia Hospital,  Post-mortem  Records,  1888,  p.  220.)    These  are  cases  of 
the  abdominal  scrofula  of  the  old  writers.      Bamberger  -  gives  an  in- 
stance, the  only  one  in  his  exi)erience,  in  which  a  woman,  at-ed  (JO,  who 
liad  vomiting,  diarrhcea  and  signs  of  marasmus,  presented  nodular 
masses  in  the  altdomen,  above  the  navel,  Avhich  were  mistaken  for 
gastric  cancer.     Post-mortem  shoxved  extensive  tuberculous  infiltra- 
tion of  the  mesenteric  glands  without  tubercles  in  other  organs. 

Besnier-^  states  that  Colin  has  described  three  cases  in  soldiers, 
in  whom  were  found  enormous  tubercular  tumors  of  the  mesenteric 
glands  without  ulcers  in  the  intestines. 

AndraP  records  tlu;  case  of  a  man,  aged  29,  with  ascites,  and  en- 
larged cervical  glands,  iu  Avliom,  with  extensive  tuberculous  periton- 
itis, an  enormous  tumoi-  was  f<.und,  due  to  infiltration  of  the  glands. 
Occasionally  in  phthisis  there  is  great  eulargeinent  of  these  bodies 
without  any  indications  during  life.  Such  a  case  was  in  the  Phila- 
deli)hia  H()si)ital  last  year  (Post-mortem  Kecords,  1888-89,  p.  60), 
with  enormous  eulargemeut  of  the  mesentci-ic  glands,  forming  large 
irregular  tumors.  Tyuipanites  may  mask  this  condition,  as  in  a  case 
given  by  Henoch  Mn  which  a  mesenteric  tumor,  the  size  of  the  child's 

.'i;°'"-"^-  '  Virchow's  Ilandbiich,  Bd.  VI,  p.  708. 

■  Dictionaire  Enc-ycloi)c'dique.    Article  Mesentery. 
♦Clinique  Medicate,  T.  ir,  p.  648,  1839.  '     s  l^,^.  ^.^^ 


iJ 


I  I 


f  - 


24 


f  ■    ■?. 


I  ' 


II  i 


head,  was  entirely  eoncealed  by  the  distension  of  the  intestines. 
Sometimes,  after  the  removal  of  tlie  ascitic  fluid,  or  when  it  is  in 
slight  amount,  there  can  lx»  lelt  irregular  nodular  bodies  or  cord-lilte 
thickenings  of  great  distinctness,  and  it  is  not  always  feasible  to 
determine  wliether  these  are  glandular  or  large  caseous  masses 
between  the  coils  of  intestines. 

A  (juestion  of  special  interest  relates  to  the  association  of  mesenteric 
gland  disease  with  tubercular  peritonitis.  Gairdner,  in  the  lectures 
already  referred  to,  has  urged  that  in  a  large  proportion  of  the  cases 
of  so-called  tabes  mescnterica,  in  which  there  is  enlargement  and 
hardness  of  the  abdomen — the  condition  which  the  French  s])eak  of 
as  r(tnrai( — there  is  involvement  of  the  peritoneum.  Jacobi  has 
recently  expressed  the  same  o})inion.' 

The  (?/«(//( o.s'/.s  ot  these  peritoneal  tubercular  tumoi-s  oil  -  difficul- 
ties which  vary  greatly  in  the  diiferent  varieties.  The  omental  tumor 
is  probably  a  less  fre(iuent  source  of  error  than  any  other,  but  as  an 
identically  similar  condition  may  exist  in  cancer,  it  is  not  always 
possible,  imless  there  is  marked  tubercular  disease  elsewhere,  to  de- 
termine the  precise  nature ;  and,  as  we  have  >^een,  even  an  acknowl- 
edged expert  like  Gairdner  may  l)e  led  astray. 

The  lumpy,  nodular  character  of  the  mesenteric  tumors  j^ives  to 
them  also  a  certain  degree  of  distinctness.  The  mistake  is  sometimes 
made,  nor  do  I  think  it  can  always  be  avoided,  of  confounding  the 
large  caseous  nodules  situated  l)etween  the  intestinal  c('ils  with  the 
mesenteric  glands.  The  possibility  of  their  re(!Ognition  depends  very 
much  on  the  degree  of  distention  of  the  bowels,  as  extreme  tympa- 
nites may  completely  cloak  a  very  large  tumor  of  this  character. 

The  tumoi-s  formed  by  contracted  and  thickened  intestinal  coils 
usually  lead  to  error  in  diagnosis,  nor  do  I  see,  save  in  most  excep- 
tional circumstances,  that  this  could  be  avoided. 

The  recognition  of  the  saciculai-  exudation,  more  particularly  its  dif- 
ferentiation from  cystic  ovarian  disease,  offei-s  really  serious  difficul- 
ties, the  extent  of  which  may  best  be  appreciated  by  the  fact  that  of 
96  cases  of  laparotomy  in  tubercular  peritonitis,  in  not  less  than  30 
ovarian  disease  was  supi)osed  to  be  present.  Such  being  the  case,  it 
may  be  worth  while  to  discuss  briefly  certain  diagnositic  details. 

*  New  York  Medical  Journal,  ii,  1889. 


25 


of  the  intestines, 
or  when  it  is  in 
(xiies  or  cord-like 
ilways  feasible  to 
e   caseous   masses 

ition  of  mesenteric 
L>r,  in  the  lectures 
rtion  of  the  cases 
enlargement  and 
3  French  speak  of 
eum.     Jacobi  has 

loi-s  oil  -  difficul- 
rhe  omental  tumor 
ly  other,  but  as  an 
,  it  is  not  always 
!  elsewhere,  to  de- 
even  an  acknowl- 

c  tumors  gives  to 
stake  is  sometimes 
f  confounding  the 
inal  e((ils  with  the 
ition  depends  very 
is  extreme  tympa- 
his  character, 
ed  intestinal  coils 
ive  in  most  excep- 

)articular]y  its  dif- 
lly  serious  difficul- 
by  the  fact  tliat  of 
n  not  less  than  30 
being  the  case,  it 
liagnositic  details. 


There  is  no  single  criterion  which  enal)les  us  to  say  in  a  given  case 
that  the  condition  is  one  of  encysted  peritonitis,  mlr  indeed  is  there 
any  special  group  of  symptoms  which  can  l)e  r(>gard(.<l  as  distinc- 
tive. It  were  folly  to  lay  down,  in  parallel  columns,  differential 
rules  in  an  affection  in  which  again  and  again  the  ablest  diagnosti- 
cians in  our  profession  have  erred. 

It  will  suffice  merely  to  touch  upon  the  points  most  suggestive,  in 
individual  cases,  of  tul)ercular  trouble  : 

First.  The  history  of  the  patient  and  of  the  disease.  Tubercular 
antecedents  are  common.  Evidence  may  exist  of  old  tubercular 
lesions.  Gradual  fiiihii'c  in  healtl,>  and  strength  mnv  perhaps  be 
taken  into  consideration,  but  it  must  not  be  forgotten  tliat  in  many  of 
the  cases  the  patients  have  been  r..bust  and  well-nourished.  The 
mode  of  onset  is  in  the  majority  of  instances  gradual,  but  tliis  is  such 
a  variable  factor  that  it  is  not  of  very  much  value  ;  perhaps  the  most 
which  can  be  said  on  this  point  is  that  ther(>  can  usuallv  be  elicited  a 
history  of  obscure  abdonu'nal  pains,  irregular  febi-ile  attacks  and  alto- 
gether a  greater  degree  of  gastro-intestinal  disturbance  than  generally 
accompanies  the  slow  evolution  of  ovarian  cysts.  If  the  case  has  been 
under  (.bservation  for  some  time,  the  fever  record  should  be  of 
great  assistance,  as  high  or  very  low  temperatures  more  commonly 
occur  in  this  condition,  though  it  is  true  that  ia  inflamed  and  snppu- 
rating  ovarian  cyst  there  may  b(!  fever  of  a  hectic  type. 

Second.  The  local  physical  signs.  If  possible,  these  are  more 
deceptive  than  the  history  and  symptoms.  The  question  is  not  so 
much  between  the  characters  of  a  sacjculated  exudation  and  ascites, 
but  it  is  the  extremely  nice  one  of  discriminating  between  two 
varieties  oi  sacculated  effusion,  ovarian  and  peritoneal.  In  typi- 
cal cases,  the  physical  signs  have  conformrd  in  everv  particular 
to  those  of  cystica  ovarian  disease.  There  are  a  few"  indications 
which  may  at  times  be  useful ;  thus  when  the  sacculated  tumor  is 
limited  and  small  the  outlines  may  not  be  so  dcHnite  and  clear  as  in 
ovarian  disease.  This  is  a  point  referred  to  by  several  writers.  The 
position  and  fol-in  may  be  variable  owing  to  alterations  in  the  calibre 
of  the  surrounding  intestinal  coils  of  which  in  part  the  walls  are 
composed.  At  the  periphery  of  the  tumor  irregular,  nodular  bodies 
—cheesy  masses— may  sometimes  be  felt,  which  in  several  instances 
have  led  to  the  diagnosis  of  malignant  disease.     Depression  of  the 


¥ 
i--' 


i 

1  V 

1 

:  :i 

'          1    • 

!  ■      ;'ii 

It  ,       '.:l' 

i 

k        '■  ■■' !' 

i  <         ■      ' 

1 

'     f  i        '      ' 

26 

vaginal  wall  is  not  a  safe  indication  one  way  or  the  other,  as  I  find 
the  condition  mentioned  as  present  in  ovarian  tnmor  as  well  as  in 
encysted  peritonitis. 

Third.  In  every  case  the  condition  of  the  tubes  and  of  the  lungs 
and  uleura  should  be  most  thoroughly  examined.  The  association 
of  a  tubal  tumor  with  an  ill-defined,  anomalous  mass  in  the  abdomi- 
nal cavity  should  arouse  suspicion  at  once.  So  also  the  evidence  of 
involvement  of  the  pleura  or  of  the  apex  of  one  lung.  It  is  rather 
surprising,  in  looking  over  the  reports  of  cases,  how  little  attention 
seems  to  have  been  paid  to  these  most  important  and  common  con- 
comitants of  tubercular  peritonitis. 

III. — The  Curability  or  Tubercular  Pkritonitis. 

Until  within  the  past  few  years,  the  general  opinion  in  the  profes- 
sion has  l)een  that  this  disease  is  incurable ;  and  in  looking  over  the 
text-books  of  medicine,  Avith  but  few  exceptions — lagge  a  notable 
one — tlie  prognosis  is  given,  as  in  the  words  of  Flint,  "always  fatal." 
Henoch,'  in  his  admirable  account  of  this  affection  in  children,  says 
that  when  recovery  has  followed  in  certain  cases  in  his  practice,  he  has 
thought  the  diagnosis  incorrect,  and  that  the  peritonitis  had  really 
been  of  the  simple  chronic  form.  Yet  there  exist  not  a  few  reports 
among  the  older  writers,  indicating  that  a  form  of  chronic  peritonitis, 
not  to  be  distinguished  from  the  tubercular,  did  occasionally  get  well. 
More  recently  McCall  Anderson,-  of  Glasgow,  in  a  clinical  lecture 
published  in  1877,  reported  three  cases  illustrating  recovery  in  tuber- 
cular jieritonitis.  The  history  and  the  symptoms  left  no  doubt  as  to 
the  correctness  of  the  diagnosis^  but  the  cases  were  regarded  as  alto- 
gether unitpie.  Gee,^  in  1881,  stated  "that  recovery  from  tubercular 
peritonitis  is  common."  Gairdner*  also  has  insisted  upon  the  occa- 
sional cure  in  this  affection,  while  admitting  that  there  was  a  hiatus 
in  our  knowledge  of  the  changes  undergone  in  the  progress  towards 
healing.  Ashby,®  in  his  article  on  peritonitis  in  children,  says  "a 
large  inunl)(>r  of  cases  completely  recover."  Fenwick,  in  his  recent 
lectures,*'  s))eaks   less   hopefully  of  permanent  cure.     The  evidence 

'  Vorlesungen  ueber  Kinderkrankheiten,  4te  Auflage,  1889.  'Lancet,  1877. 

'Lancet,  Jan.  1st,  1881.  *Loc.  cit. 

'  Cyclopedia  of  Diseases  of  Children.     Edited  by  Keating.     Vol.  iii,  1890. 
'  Loc.  cit. 


;he  other,  as  I  find 
umor  as  well  as  in 

es  and  of  the  lungs 
I.  The  association 
lass  in  the  abdomi- 
i?o  the  evidence  of 
lung.  It  is  rather 
low  little  attention 
and  common  con- 


Peritonitis. 

in  ion  in  the  profes- 
n  looking  over  the 
— Fagge  a  notable 
int,  "always  fatal." 
)n  in  children,  says 
his  practice,  he  has 
•itonitis  had  really 
t  not  a  few  reports 
chronic  peritonitis, 
casionally  get  well. 
1  a  clinical  lecture 
;■  recovery  in  tuber- 
left  no  doubt  as  to 
■i  regarded  as  alto- 
ry  from  tubercular 
:ed  upon  the  occa- 
there  was  a  hiatus 
B  progress  towards 
children,  says  "a 
iwick,  in  his  recent 
ire.     The  evidence 

«  Lancet,  1877. 
Vol.  Ill,  1890. 


I 


27 

has  been  rapidly  accumulating  to  show  that  in  a  considerable  number 
of  cases,  recovery  in  this  disease  is  possible,  either  spontaneouslv  or 
after  operative  interference. 

(a.)  SponlaneoHx  Cure. 

There  is  no  inherent  imj)robabih-ty  why  tubercles  on  the  per- 
itoneum should  not  undergo  involution  as  they  do  elsewhere  4na- 
tomieally  the  peritoneal  growth  bears  in  its  evoluti.m  a  close 
analogy  to  the  pulmonary,  and  tliife  is  still  further  borne  out 
by  the  retrograde  ehat.ges  through  whieli  it  passes.  Just  as  the 
aggregations  of  miliary  nodules  in  the  lung  may  uiKl<M-go  the  ('han-res 
which  we  speak  of  as  healing,  bec.)ming  hard  and  fibroid,  so  in  Hie 
peritoneum  the  tubercle  tends  in  many  cases  to  become  sclerotic,  and 
passes  mto  a  condition  in  wliich  it  is  practically  harmless  Tiiis 
beneficial  result  is  more  likely  to  be  seen  in  cases  belongin-  to  the 
third  group,  in  wliic-h,  from  the  outset,  the  process  is  sul)-ac".te  and 
not  associated  with  much  exudation;  l,ut  there  are  cases  on  record 
111  which  recovery  has  followed  even  after  extensive  etiusion. 

The  anatomical  changes  are,  in  brief,  these  :  fibroid  and  pigmeniarv 
induration  of  the  tubercles,  absorption  of  the  exu.late,  transformation 
of  the  fibrinous  material  into  connective  tissue,  with  tlie  union  to  a 
greater  or  lesser  extent  of  the  intestinal  coils  and  of  the  peritoneal 
surfaces  with  each  other.    The  following  case  illustrates  tliis  condition : 

Case  VI.— a(ron/(;  tympanites,  with  constipation;  gradual  develop- 
ment of  pulmonary  syviptow  death;  adhesire  peritonitis  tvith 
fibroid  tubercles.     Pulmonary  tuberculosis. 

W.  C,  age  38,  colored,  admitted  to  the  University  Hospital  Phila- 
delphia on  the  18th  of  January,  1888.  His  father"  died  of  phthisis. 
He  had  been  a  healthy  laboring  man  of  temperate  habits.  He  had 
not  had  any  serious  illness.  About  four  weeks  before  admission  he 
fii-st  noticed  distension  of  the  abdomen  and  he  found  that  it  was  diflfi- 
cult^to  button  his  clothes.    For  some  time  he  had  been  very  constipated. 

Following  note  was  made  on  admission :  "  The  patient  is  fairly  well 
nourished,  says  he  has  not  lost  in  weight,  complains  of  swollen  abdomen 
and  constipation;  temperature  101.,3° ;  pulse  82.  On  examination 
nniform  enlargement  of  the  abdomen,  measuring  72  cm. ;   respira- 


28 


til  ii 


tion  is  costo-abdominal.     On  palpation,  soft,  no  special  roaistance  ; 
percussion  gives   resonance   anteriorly  and  in  the  flanks;    in  illiac 
regions  resonance  not  so  ftill  ;   tlicrc;  is   no  dullness,  no  }>ercussion 
wave.      Neither  liver  nor  spleen  palp:il)l('.      Area  of  liver  dullness 
diminished;  two  inches  of  vertical  splenit;  dullness."     The  case  was 
regarded  for  a  tiine  as  on(!  of  ordinary  tympanitic  distention,  associ- 
ated with  sluggish  and  constipated  howels.     The  jx-rsistent  elevation 
of  temperature  ranging  from  99°  to  102°  and  slight  tenderness  in  the 
flanks,  with  recurring  night  sweats,  aroused  a  suspicion  of  tuhercular 
trouble,  but  the  examination  of  tiu!  lungs  was  negative.     Throughout 
the  month  of  February,  there  was  a  daily  elevation  of  from  1  to  3 
degrees ;    he  lost  Hesh  and  began  to   cough ;    there    was,   however, 
no  expectoration,  but  examination  determined  a  few  scattered  rales, 
most  marked  at  the  left  apex,  behind.     During  ]\[ar{;h  he  continued 
to  lose  in  weight,  the  sweats  were  less  troublesome,  the  temperature 
rarely  rose  above  101°  ;  the  condition  of  the  abdomen  remained  the 
same  ;  there  was  slight  tenderness  in  the  flanks  ;  no  dullness  ;  measure- 
ment about  75  cm. ;  no  signs  of  effusion  could  at  any  time  be  discov- 
ered ;  the  local  disease   had  at  the  left  apex  behind  become  more 
marked,  the  breathing  was  slightly  tubular  and  there  were  numerous 
mucous   rfdes.     The   constipation   remained  a  marked  feature,  the 
bowels  were  never  moved  without  a  purge  or  an  enema.     He  gradu- 
ally failed  without  any  further  development  of  the  pulmonary  symp- 
toms, and  death  occurred  on  the  19th  of  March.     The  post-mortem 
showed  disease  of  the  left  lung,  partly  old,  with  slight  fibroid  change 
and  many  recent  tubercles  and  eheesey  masses.     In  the  abdomen,  the 
peritoneum  was  obliterated  by  imivcrsal  adhesions  between  the  layers. 
The  coils  of  small  intestines  were  united  together  by  old  fibrinous 
bands ;  here  and  there  in  the  adhesion  were  pigmentations  and  small, 
hard,  dark  tubercles,     Nimierous  adhesions  existed  over  the  liver, 
uniting  it  strongly  to  the  diaphragm,  and  in  these,  too,  there  were 
many  old  fibroid  tubercles. 

Here  the  peritoneal  disease  was  practically  cured,  but  the  ill  effects 
remained  in  the  weakening  of  the  intestines.  The  pulmonary  not 
the  abdominal  affection  caused  death. 


Similar  ca.ses  might  be  drawn  from  the    records  of  any  path- 
ologist of  large  experience.     In  Cases  XIII  and  XIV  of  my  series, 


2{» 


.special  rcsiataiK-e  ; 
■  Hanks ;  in  i Iliac 
ess,  no  |)ertMis.sion 

of  liver  dullness 
IS.        I  lie  case  was 

distention,  assoei- 
)ersistent  elevation 
t  tenderness  in  the 
icioii  of  tuhercular 
:ive,  Throii<f|iout 
ion  of  from  1  to  3 
re  was,  however, 
ew  scattered  rA,les, 
xrcli  he  continued 
i,  the  temperature 
men  remained  the 
lullness ;  measure- 
ly  time  be  discov- 
ind  become  more 
re  were  numerous 
rked  feature,  the 
lema.  He  gradu- 
pulmonary  symp- 
The  post-mortem 
lilt  fil)roi<l  change 

the  abdomen,  the 
letween  the  layers. 
'  by  old  fibrinous 
tations  and  small, 
•d  over  the  liver, 
B,  too,  there  were 

but  the  ill  effects 
18  pulmonary  not 


ds  of  any  path- 
IIV  of  mv  series. 


an  identical  condition  exist<..l.     In  both,  death  to„k  place  from  nul- 

n.onary  disease,  m.d  the  peritoneum  presented  universal  adiu's -  in 

winch  were  hard,  deeply-pigmented  fibroid  tubercles 

In  this  connection  the  eases  which  (Jairdner  gives  in  the  appendix  to 
his  lectures  are  of  tl...  greatest  interest,  as  three  of  them  illustrate  this 
gradual  improvement  in  midoubtcd  tubercular  disciise      In  Case  I  a 
cWId,  aged  S    pirsented  signs  of  peritoneal  disease,  with  inod<.nUc 
effusion,  and  later,  thickening  of  the  great  omentum.     The  impnu'c- 
ment  within  three  months  was  remarkabl,.,  though  sliuht  induration 
ot  the  omentum  remained.     The  improvenu-nt  continued   and   two 
y.'ars  subscpiently  the  patient  was  well.      In  Case  III,  the  improve- 
ment was  also  most  striking  under  simple  treatment  ;  the  etfusion 
disappeared,  but  evidence  of  omental  thickening  persisted      ( 'a<e  IV 
.s  still  more  remarkable.     X  child,  aged  i»,  presented  well-marked 
thickening  of  the  omentum,  and  other  symptoms  pointing  to  peri- 
toneal involvement.      Duri-ig  the  two  years  she  was  under  ..bservation 
the  general  health  improved  and  a  gradual  resolution  of  th<'  ..mental 
tumor  took  place. 

No  writer  has  dealt  with  this  aspect  of  the  question,  so  fiillv  and 
clearly  as  Boulland.'     He  has  ransa.-ked  the  literature  of  the  subject 
and  in  his  collection  of  eighty-one  cases  in  which  tubercle  occurred  in 
the  i>l(niro-peritoneal  membranes,  there  are  at  least  t\ventv  cases  of 
peritoneal  tuberculosis  in  which  recovery  took  place.      He  places  the 
number  of  recoveries  much  higher  than  this,  but  I  have  excludcKl 
many  doubtful  cases  on  his  list.     In  many  instances,  of  course,  this 
may  have  been  only  a  temporary  improvement,  iiut  in  three>  instances 
quoted  from  Buequoy,  the  good  health  persisted  ten,  twelve  and  sev- 
enteen years  after  recovery.     The  subsequent  history   of  operative 
cases  removes  all  grounds  for  skepticism— reasonable  perhaps  a  few 
years  ago— as  to  the  genuineness  of  these  cases.     One  of  the  most 
interesting  of  the  cases  quoted  by  Boulland  is  from  Louis.     A  man 
aged  24,  with  great  enlargement  of  the  abdomen,  signs  of  pleural 
affection  and  extreme  marasmus,  was  attacked  with  Asiatic  cholera. 
He  nearly  died  from  the  excessive  purging,  but  the  abdominal  effu- 
sion disappeared  and  he  ultimately  made  a  good  recovery.     In  read- 
ing the  details  of  the  long  list  of  cases  given  uy  Boulland,  one  receives 
the  impression  that  the  cure  of  tubercular  peritonitis  cannot  be  a  very 
'  Loc.  cit. 


4'     ( 


\ 

1 

1 

;f 

■       i 

f 

H      ^ 

,1^  ' 

1  ^ 

1 

if 

Jm  i 

1  ■ 

ii 

IB  '^ 

^/M 

i 

, 

III  j^ 


30 

iiiHMmtuoii  event,  ('use  ITI,  to  whioh  [  have  already  referred,  as 
siiniilatinjf  ty|)h()id,  is  an  illustration,  I  have  no  doubt,  of  a  elinieal 
group  by  no  means  rare.  The  following  is  an  interesting  example  of 
marked  improvement  in,  if  not  aetiial  healing  of  peritoneal  tuberculosis : 

Case  VI  I. — IILstori/  <>/  >in  olm-urc  ahdominal  ajfirtioii  irlthfci'cr  and 
/».s,v  qffloili.  irnidnal  liiiprooriiient.  lU-dcJined  ahdomhud  tainor. 
Local  disaiHC  of  fhe  luu;/f*.  Pifpncntation  of  flic  skin.  Marked, 
iiiiproremrnf. 

A.  B,,  aged  31,  merchant,  admitted  to  the  Johns  IFopkins  ITospital 
May  18th,  liS(S}>,  complaining  of  swelling  and  distress  in  the  abdo- 
men, with  weakness  and  loss  of  Hesh. 

Family  history  is  good.  Father  and  mother  living  and  healthy  ; 
two  brothers  living;  two  sisters  died  when  children. 

He  had  dysentery  15  years  ago  and  with  that  exception  has  always 
enjoyed  good  healtii  until  October,  1888,  when,  after  exposure  to 
cold,  he  hiul  an  attack  of  obscure  trou!)le  in  i'.c  abdomen.  There 
were  swelling,  tenderness  and  a  sense  of  distension  and  weight,  par- 
ticularly in  the  region  of  the  liver.  There  was  no  diarrhcca,  rather 
constipation.  Me  lost  Hesh  and  became  extremely  weak.  At  Christ- 
mas he  \vas  up  and  about,  and  in  January  attended  to  his  business. 
The  strained,  distressed  feeling  in  abdomen  ))ersisted.  Throughout 
Februaxy  and  March  he  remained  pretty  well,  though  far  from  his 
usual  condition  of  health.  The  swelling  of  the  abdomen  subsided 
greatly.  Early  in  ^\.pril  the  distention  increased  again  so  that  he 
could  not  button  his  trousers,  but  he  had  neither  pain,  diarrha>a,  nor 
fever.     He  again  lost  Hesh  rapidly. 

Condition  on  admission:  Large  boned  man,  5  ft.  Ill  in  height; 
marked  emaciati(m  ;  orbital  fat  much  wasted  ;  eyes  sunken,  with  deep, 
dark  rings  about  them  ;  cheeks  very  hollow.  The  forehead,  cheeks 
and  (shin  were  distinctly  pigmented  ;  this  darkening  in  color  he  had 
noticed  gradually  coming  on  since  October.  The  skin  of  abdomen 
and  backs  of  hands  were  also  pigmented.  The  chest  was  large  ;  ribs 
prominent.  P]xpansion  was  deHcient  at  left  base.  Percussion  was 
clear  with  the  exception  of  the  left  base,  where  the  resonance  was  slightly 
defective  and  here  fremitus  wa.s  diminished.  There  v.'as  also  slightly 
defective  resonance  at  right  apex  and  the  right  clavicle  was  more 
prominent  than  the  left.     On  auscultation  there  was  feeble  breathinir 


rciuly  reterntl,  as 
oiibt,  of  a  clinical 
•cstinj^  example  of 
oneal  tuberculosis: 

tion  wUh/enr  (tnd 

abdonibuil  tiunor. 

'he  xk'm.      Marked 

IFopkiiis  I  lospital 
tress  in  tite  ubdo- 

/in^  and  healthy  ; 

■(>j)tion  has  always 
after  exposure  to 
abdomen.     There 

and  weight,  par- 
>  diarrhrea,  rather 
k-eak.  At  (.'hrist- 
ed  to  his  business, 
ted.  Throughout 
)ugh  far  from  his 
abdomen  subsided 

again  so  that  he 
lin,  diarrho'a,  nor 

ft.  Wl  in  height; 
sunken,  with  deep, 
3  forehead,  cheeks 
■x,  in  color  he  had 
skin  of  abdomen 
■^t  was  large  ;  ribs 
Percussion  was 
nance  was  slightly 
3  v/as  also  slightly 
lavicle  was  more 
s  feeble  breathing 


31 

with  fine  nlles  in  tiie  lower  axillary  and  infra-scapuhir  regions.  The 
contra.st  between  the  two  sides  was  most  marked.  At  the  right  apex 
there  were  moist  soimds  heard  just  beneath  the  clavicle,  and  behind 
in  th(!  upper  part  of  inter-sca])ular  area. 

Abdunien  was  moderately  distended,  uniform.  Xo  fluid  dise<.ver- 
able.  Flanks  were  tympanitic.  The  resonance  was  defective  just 
below  and  to  the  hjft  of  the  navel,  in  an  areaeipial  in  si/eto  the  palm 
of  the  hand.  On  palpation,  no  tenderness,  but  in  the  region  Im'Iow 
and  to  the  left  of  the  navel  there  was  an  ill-defined,  tumor-like  nniss, 
r&sistant,  not  painful  but  slightly  tender  on  deep  pressure.  It  was 
readily  separable  from  liver  and  spleen.  Helow,  the  margin  was  well 
defined, 

Fiiver  dullness  not  increased.  Kdge  of  spleen  not  pal  pal  )le.  In- 
guinal glands  not  enlarged.  \o  t<iiderness  in  renal  n>gions.  The 
temperature  was  subnormal.  Trine  negative,  not  increased  in 
amount.  He  luul  slight  morning  exixrtoration,  nuico-purulent  in 
character,  which  did  not  contain  tub<!rcle  bacilli,  but  in  which  once 
elastic  tissue  was  found. 

Patient  improved  rapidly  in  Hospital.  Abdomen  reduced  in  size. 
lie  gain(«d  in  weight.  June  (Jth  he  went  to  Atlantic  City,  where  he 
improved  in  a  remarkable  manner.  He  returned  on  the  lOth,  having 
gained  over  'Jo  pounds  since  his  first  entrance  to  Hospital.  He  had 
no  (jongh.  The  color  had  imju-oved  and  he  had  lost  the  characteristic 
abdominal  fiicies.  The  examination  of  the  lungs  showed  that  the 
note  at  the  left  base  was  clearer ;  there  was  a  dry  friction  rub  in 
the  lower  left  axillary  region.  Rilles  still  ijersisted  at  the  ai)ex.  The 
abdomen  was  a  little  fidl,  though  not  so  much  so  as  at  first.  There 
was  a  distinct  prominence  to  the  lefl  of  the  navel,  and  here  the 
same  obscure  tumor-like  mass  (iould  be  felt.  In  the  right  inguinal 
region  about  two  inches  above  Poupart  ligament,  there  was  also 
a  distinct,  ridge-like  projection  which  was  not  noticed  at  previous 
examinations. 

The  temperature  range  of  this  patient  during  his  stay  in  the  Hospital 
was  very  carefidly  studied.  For  days  at  a  time  two  hourly  observations 
were  made.  Unfortunately  the  charts  were  mislaid,  but  the  general 
results  may  be  stated  as  follows  :  The  range  was  between  96°  and  99°. 
The  temperature  fell  throughout  the  morning  hours,  and  by  6  or 
8  A.  M.  reacht4  the  minimum,  then  gradually  rose  through  the  fore- 
3 


ill 


I 


h 


Sfii- 


lloi 


III    iliul    ()ll|\     ICilcllcd 


Tl 

oft, 


32 


1  iiorriial  |Hiiiit  in  tlic  Ijilc  iifhTtidon  I 


»•  ixTsiHtcnt  l«.\v  l(iii|)cmtuiv  was  one  oftl 


KHirB. 


U'  <'ilH(', 


must  striking-  rraliiros 


'I'lic  patit'iit   rcttinicd  to  his  lioin 


••  111  a 


VV'(.st( 


.      ,       ,,  tern  .state,  ami    lias 

mnaii...<l  uvjl  ,.v(t  si.ur.      II,.  was  svni  hy  Dr.  T..Ml,Mii.  i„  OcIuIkt, 
wlicii  tlic  (toiiditiuii  ot'>.iHMl  health  prrsistcd. 

The  attack  in  18MS,  with  swllino.  and  tenderness  „f  the  alulon,..,, 
and  lossot  MeHh,  was,  without  .,ne.stion,  I  shu.dd  huv,  tiii.erenlosis  of 
the  pentonemn.  The  exist.-ne.-  ut'  tl...  tiimor-Iik,:  mass,  fh,.  snb- 
mmnal  t,.m|.eratnre,.nrv<.,  the  si.rns  of  inv..lv,.ment  of  the  plenraand 
of  th..  Inn^',  the  dillus..  |.i-m<'ntati<.n— all  point  to  t!,e  exist..|i(.,.  of 
tins  atleet.on.  The  st.ikiiijr  in.p,ov..m..nt  u  hi..h  ....ewiTed  throuc-hont 
May  an.l  .lime  has  persisted,  and  I  see  no  reason  why  a  permanent 
••ure  shonid  not  be  established. 

The  <as<-s  which  are  most  likely  to  terminate  fiivomblv  arc  those 
in  whic-h  the  infl.crion  is  limited  to  the  p,.ritoneiin.,  the  inflamniati.w. 
ol  moderate  grade  and  the  c.ir.ision  slight  in  amount  and  s<.ro-(il,rinons 
Ihe  instances  I  have  given  in  illustration  of  the  latem^y  of  the  disease 
would  seem  t(n-ndicate  that  an  adhesive  inflammation,  as  it  is  termed 
may  accompany   the   process  from  the  outset,  and  that  a  gradual 
sclerosis  may  overtake  the  tubercles  and  r,.nd(.r  th.^m  hannh.ss.    Case- 
ation and  ulceration,   with  a  sero-puruk.nt  (.xiidation,  preclud..  the 
possibility  of  spontaneous  cure.     Extension  to  the  ph.ura  and  lun-rs 
and   the   eo-existence   of  intestinal   or   tubal  disease  are  conditions 
equally  unfavorable  to  permanent  recovery. 

(I).)  Cure  hy  Operation. 

The   benefi(.ial  effects  which,  in  a  number  of  ,.ases,  followed  the 
oi)cning  of  the  ])eritonenm  when  a  sacculated  exudation  was  mistaken 
for  ovarian  tumor,  encouraged   surgeons  to  perform  laparotomy  in 
ordinary  cases  of  tubercular  peritonitis  accompam'ed  with  much  effu- 
sion.    Sir  Spencer  Wells,  in  18(J2,  performed  laparotomy  ,m  a  patient 
believed  to  be;  the  subject  of  ovarian  tumor,  but  in  whom  the  condi- 
tion was  found  to  be  tubercular  peritonitis.     The  effusion  was  with- 
drawn and  the  i)atient  recovered.      She  married  and  at  last  report, 
twenty-five  years  after  the  operation,  maintained  her  good  health.' 
The  operation,  thus  unintentionally  carried  out  in  this  and  many 


ilh'niiKiii  liuiirs. 
^rikiii^'  Iratiircs 

State,   1111(1    liiLs 
iiiin  ill  Octohcr, 

i)i  the  nlxloiiu'ii 
,  tllbcrciilnsis  of 
mass,  the  siib- 
'tlic  plfiira  and 
llic  existence  of 
•red  tliroiiolioiit 
ly  a  peiinanent 

lably  are  those 
e  inflammation 
.son)-fil)rinons. 
V  of  tlie  disease 
•is  it  is  tiTmed, 
liat  a  fiiadiial 
irndoss.  Casc- 
,  l)reclud('  tlu; 
m-a  and  lnn<rs 
lire  conditions 


followed  the 
was  mistaken 
aparotoniy  in 
til  nuu'h  eti'n- 
y  on  a  patient 
>ni  the  fondi- 
ion  was  with- 
it  last  report, 
good  health, 
is  and  manv 


33 

8nhMM,u,.nt  cases,  was  advoeattd  strongly  l.v  nej.ar '  and  hy  Koenin" 
in  (i.rinany,  l.y  I.awson  Tait  in  Kiij-lund,  and  lias  >inee  been  pnu- 
ti.r<l  l.y  many  surgeons  in  Kiin.pe  ;  i.nd  in  this  e.,nntrv  l.v  Iloniaiis 
ol  nn>t..n,  .M,in(le..f  New  Y..rk,  (;,m„|,.||  of  I'liiladelpliia',  Krils  of 
Baltinn.re,  (Janliier  of  Montreal,  and  others. 

In  two  eases  reeently  under  tivatnient  in  the  Hospital,  laparotomv 
has  been  performed,  in  one  i;,r  tnberenlar  peritonitis,  thon^di  a  .lo.ibt 
existed  whether  (.r  not  a  tumor  was  pres.-nt  ;  in  the  other  an  ovarian 
tnmor  was  found  aeeidentally  to  be  eumplieated  with  a  latent  perito- 
nitis, '{'he  first  euse  pivs..nts  ieafiires  of  very  special  ii.teiv.t,  as  rapid 
amelioration  Ibllowed  the  removal  of  the  fluid,  uhile  the  death  fr.mi 
acute  disease,  after  .onvaleseen.v  was  established,  enabled  ns  to  stialy 
the  ehanoes  in  the  peritonenm  which  are  associated  with  the  healin.r 
of  tiibcnuilar  processes.  " 

Cask  V  [  I  l.—llidnry  of  olm-nre  alulumliHil lrna/>/r  for  .srrcmf.  nwul/ti^; 
acute  rwarerbaflon  wit/,  hhjl,  /,,vv.  IhuUful' ahdonunal  tnmor. 
Laparotnoii/,  dnrnuujc  ;  mphl  Improvement,  nisrhnyed,  fer/hu/ 
well.  RetarH  with  acute  pne.vmo,il,i,  death.  Chronic  tuh'erculnr 
peritonitis  in  proeexn  ofhealin;/.    S,,philix  of  rectum.    A  m,/loid  lira; 

Emma  G.,  i-    28,  admitted  August  28th,  complaining  of  pains  in 
abdomen. 

^  Father  and   i.K.ther  probably   liv-'ng,  one  bn.ther  and  one  sister 
living;  tw..  sisters  and  two  bn.thers  <h"ad,  none  of  them  of  lung  dis- 
ease.    Had  whoopiiin.-,,,„gh  and  meash's  as  a  child;  ten  years  ago 
had  pleuro-pneiimonia,  was  ill  Hve  months  and  has  iK.t  beenVerfectly 
well  since.     For  five  years  she  has  had  a  cough,  on  and  ..If,  and  <.n 
several  occasions  has  spat  blood  ;  has  bad  n(.  special  illness  since  the 
attack  ten  years  ag<.,  but  several  times  In  the  spring  or  autumn  she 
has  been  in  b(>d  with  weakness  and  shortness  (.f  breath.     Her  present 
trouble  began  aln.ut  six  tncmths  ago  with  swelling  of  abdomen,  which 
has  been  variable  in  extent  and  has  on  several  occasions  almost  dis-' 
aj)|)eared.     She  has  generally  been  constipated,  lia.s  been  short  of 
breath  and  has  had  palpitation  of  the  heart.     She  had  been  working  up 
to  a  few  days  before  applying  to  Hospital.     On  admission  the  fol- 
lowing note  was  made:    "Temperature  101°.     Patient  is  a  well- 


^! 


'  Loc.  cit. 


•Centrulblatt  fur  Chururgie,  1884. 


# 


i 

1 

1' 

i  h 

34 

grown,  not  emaciated  woman.     The  tongue   i.s  coated  white.     The 
abdomen  ,s  ,nuch  distended,  measures  86  centimetres;  it  is  symmet- 
ncal,  extremely  tender  to  toneh  in  the  npper  zone,  particularly  below 
he  r,o-ht  ,<,stal  n.argm.     Ti.e  lower  zom-  is  more  flaccid  and  less 
<;nder.     ()„  percussion,  ^^•hen  lying  on  back  the  flanks  are  dull,  um- 
l.ihcd  region  resonant;  on  changing  posture,  flanks  become  resonant 
an.   the  fl,n<l  gravitates  towards  the  t^^ntre  of  abdomen.     The  liver 
dulluess  reaches  from  fifth  rib  to  nearly  two  inches  below  costal  mar- 
gu..     Botli  percussion  and  palpation  in  this  region  very  diffieult  on 
account  of  the  ex(,nisite  tenderness  in  epij-astrinm.     The.-e  is  dull- 
ness from  the  ensiform  <-artilage  7  cm.  do^^n^^ard.     There  are  nodes 
on  the  tibia..      luguiual  glands  slightly  enlarged.      The  heart  sounds 
are  normal.     Lungs,  percussion  clear  anteriorlv  ;  resonance  is  defec- 
tive at  the  extreme  base  on  the  right  side;  tliere  is  tenderness  here 
Z^C^l  1030     ''"'P''^^''""^"  ''""S^  ""^'■'  '^^I'^-»f^^'r  Che  4th  ^^as 

Both  Dr.  Lafleur   who  first  saw  tlie  case,  and  Dr.  Atkinson,  who 
joined  hun  ,n  consultation,  regarded  it  as  one  of  peritonitis.     There 
was,  h.nveyer,  a  doubt  about  the  extremely  tender  area  belo^v  the 
right  c,,stal  margin,  and  here  Dr.  ITalstcl  thought  there  w.-.v  indica- 
tions of  a  distinct  tumor,  possibly  a  gall  bladder.     On  the  4th  an 
exploratory  laparotomy  ^^•a<  made.     The  incision  extended  from  the 
costal  border  2  5  cm.  to  the  right  of  median  line.     The  peritoneum 
was  found  filled  with  a  bloody  serum.     The  liver  seemed  enlarged 
1  he  capsule  was  studded  with  tuberculous  nodules.     The  intestines 
were  matted  together  and  the  layers  of  tlu-  peritoneum  presented 
tubercu  es.      1  he  cavity  of  the  abdomen  was  drained  and  then  washed 
out  vvith  ster.  ized  salt  solution.     Histological  examination  bv  Dr 
Councilman    showed    the   tuberculous    character   of  the   i>eritoneai 
growths.  ' 

The  temperature  on  the  evening  of  the  4th  w  i-  '  04°  She  rallied 
well  from  the  operation.  The  temperature  fluctuated  from  99°  to 
102  until  the  14th,  when  it  fell  to  98°,  from  which  date  until  the 
30th  the  range  was  from  98°  to  100°.  Her  general  condition  im- 
proved very  rapidly  and  she  was  up  at  the  end  of  a  mouth  She 
had  no  cough  and  expressed  herself  much  better.  She  was  about  the 
ward,  and  <m  the  22d  of  Oetober,  six  weeks  after  the  operation,  the 
following  not^  was  made  :  "  General  condition  continues  good  •  she  is 


ited  white.     The 
e.s ;  it  is  syramet- 
)articularly  below 
flaccid  and  less 
nks  arc  dull,  iim- 
bocome  resonant 
men.     The  liver 
)elow  costal  mar- 
very  difficult  on 
There  is  dull- 
There  are  nodes 
riie  heart  sounds 
■^oiiance  is  defec- 
tenderiiess  here 
iber  fhe  4th  was 

Atkinson,  who 
itonitis.  There 
area  belo\v  the 
ere  were  indiea- 
On  the  4th  an 
ended  from  the 
rhe  peritoneiun 
:emed  enlar<>ed. 

The  intestines 
eum  presented 
lid  then  washed 
iuation  by  Dr, 
the   ])eritoneal 

^  8he  rallied 
i  from  99°  to 
date  until  the 
condition  im- 
month.  She 
was  about  the 
oi)ei-ation,  the 
s  good  ;  she  is 


35 

up  every  day  ;  the  abdomen  is  still  a  little  distended,  and  on  palpation 
is  tender  on  right  side,  and  there  is  here  l)etween  costal  margin  and 
illiac  region  a  well-deflned  firm  swelling,  slightly  resistant  and  very 
tender.  On  percussion  there  is  tympany  in  umbilical  and  left  lateral 
regions  almost  to  the  back  ;  to  the  right  there  is  dullness  from  5  cm. 
beyond  the  navel.  On  firmer  percussion  flat  tympanv  can  be  elicited 
except  in  the  extreme  right  flank  where  it  is  dull."  She  continued  to 
improve  through  November,  and  on  December  12th  she  was  dis- 
charged.    The  following  note  was  made  : 

"Patient  wont  out  to-day  feeling  quite  well.  All  signs  of  tumor 
have  disappeared ;  the  abdomen  is  soft,  but  in  the  right  hvpochon- 
driac  region  a  little  more  resistant  than  elsewhere ;  here,  "too,  it  is 
now  tympanitic." 

The  temperature  had  been  normal  and  sub-normal  for  weeks. 

The  patrent  was  re-admitted  January  8th,  with  lever  and  urgent 
dyspcona. 

She  stated  that  she  had  been  at  work  since  her  dis(;liarge.  On 
December  :]Oth,  she  had  a  slight  chill,  followed  by  fever  and  cough. 
On  January  4th,  she  had  another  chill,  with  quite' high  fever,  and°on 
that  day  went  to  bed.  (Jn  admission  her  temperature  was  102°,  res- 
piration GO,  pulse  120;  physical  signs  showed  an  extensive  area  of 
consolidation  in  the  right  lower  lobe,  which  extended  anteriorly  to  the 
nipple  line  and  as  high  as  the  fourth  rib.  The  sputum  was  muco- 
purulent, a  little  blood-tinged  and  contained  numerous  pneumococci 
but  no  tubercle  baccilli.  The  abdoiuiui  was  not  specially  distended, 
but  was  quite  tender  in  the  upper  zone.  On  the  11th  and  12th  she 
seemed  bettei-  but  the  physical  signs  persisted.  Tem].erature  was  not 
high,  never  reaching  above  102.5°.  ( )n  the  14tli,  she  passed  blood  in  • 
the  stool,  and  in  the  evening  she  had  a  i)rofuse  hemorrhage  from  the 
bowels  and  died  at  10.20  p.  m. 

The  following  is  a  condensed  report  from  the  autopsy  record  by 
Dr.  Councilman  :  A  well-built,  wi-U-nourished  woman. "  A  smooth 
cicati-ix  extended  diagonally  across  the  abdomen,  14  cm.  in  length. 
Pigmented  macular  scars  over  flu  entire  body,  more  marked  on  the 
anterior  stu'face. 

Peritonemn  adherent  to  anterior  abdominal  wall  over  the  liver.  A 
few  slight  adhesions  with  the  omentum.     ^Fhe  adhesions  over  the  liver 


if 


f 

I' 


36 


wcro  firm,  and  contained 


:i 


i>  good  deal  of  fat.     Here  and  th 


(ire  in  the 


udl.esmns  wore  firm,  wln-tisl,  nodnles,  Mhiel,  varied  in  size  from  a  pin's 
iK'ad  np  to  3  mm.  in  diameter.    The  omentum  was  thickened,  its  nm)er 
snrtaee  smooth,  its  lower  surface  covered  witi,  numerous  small,  up  to 
2  mm.  m  size,  firm,  nodules,  especially  numerous  along  the  thick<.ned 
...  er.or    horder.      A[ost    of  these    were    pigmented.     No   adhesions 
between  ,nt,.st.nal  coils.     Over  peritone.1  s.u-face,  n..merous  small, 
hvm  nod.des  slightly  pigmented.     Many  of  these  were  seated  flat  on 
tlie  peritoneum,  others  in  small  connective  tissue  bands,  attached  l)v 
one  cud  to  the  serous  surface.     The  tubercles  were  generally  seated  at 
the  cue    of  these.     They  extcndc<l,  with  about  the  same  frequency 
along  the  entire  length  of  small  iutestin,>,  but  were  most  numerous 
or  .0  cm.  above  the  valve.     The  large  intc.stine  on  its  surface  con- 
tained very  tew  of  these  nodules.     The  mesentery  contained  numerous 
tubercles,  partly  seated  on  the  membrane,  partly  along  the  intestinal 
border,  ,,,  a  f(.^v  places  matted  together.      The  surface  surroundii... 
them  WMS  thickened  and  puckered  as  though  from  slight  cicatricial 
tormation.      Nearly  all  of  these  contained  in  the  tubercle  dark  pio-. 
ment.     The  posterior  surfao  cont^iined  a  few,  and  gen.Tally  smaller 
tul)ercles  than  on  the  omentum. 

In  the  right  pleural  sue,  400  cc.  of  purulent  fluid  with  flakes  of 
tiDrin  Ihe  pericardial  membranes  were  adherent,  slightly  thick- 
ened but  presented  no  evid.mce  of  either  tubercle  or  caseation.  The 
heart  showed  no  S})ecial  changes. 

Lungs.    The  left  was  bound  down  by  old,  tol,>rably  firm  adhesions. 
Ihe  tissue  was  crepitant.     Muco-pus  could   be  squeezed  from  the 
small  bro.u.hi.     Right  lung  slightly  adherent  at  base,  somewhat  c-om- 
pressed  by  the  pleuritic  exudation.     The  entire  pleural  surface  cov- 
ered with  fresh  exudati.m  \\hich  (,ould  be  stripped  off.     The  lower 
lobe,  the  middle  lobe  and  part  of  the  upper  lobe  were  solidified. 
Cut  surface  smooth  and  reddish  in  color,  and  from  it  a  reddish  fluid 
coi.ld   be  squeezed.     The  posterior  parts  of  the  upper  and  middle 
lobes  were  grayer  in  color  than  elsewhere.     Portions  excised  sank  in 
water.      1  he  bronchial  glands  large,  pigmented,  not  caseous 
_  Liver  was  large,  weighed  2910  grammes;  the  entire  surface,  espe- 
cially the  upper,  was  covered  with  adhesions,  in  which  and  in  tlie 
capsule  there  were  numerous  tubercles,  either  single  firm  nodules 
or  flattened  masses.     Even  when  these  were  apparentiv  situated  in 


37 


and  there  in  the 
1  size  from  a  pin's 
ifikeiied,  its  npper 
rons  small,  up  to 
•ng  the  thickened 
i     No    adhesions 
numerous  small, 
^re  seated  flat  on 
nds,  attached  In- 
Mierally  s(>atcd  at 
same  frequency, 
most  numerous 
its  surface  con- 
tained numerous 
ig  the  intestinal 
ace  surrounding 
slight  cicatricial 
)ercle  dark  pig- 
encrally  smaller 

!  with  flakes  of 

slightly  thick- 

:'aseation.     The 

firm  adhesions, 
eezed  from  the 
somewhat  com- 
al  surface  cov- 
ff.  The  lower 
kvere  solidified, 
a  reddish  fluid 
er  and  middle 
ixclsed  sank  in 
Lseous. 

3  surface,  espe- 
ich  and  in  the 
!  firm  nodules 
tly  situated  in 


the  liver  surface  they  could  be  stripped  off  with  the  capsule,  which 
was  very  much  thickened.  In  reality  this  was  not  the  capsule,  but 
a  thickened  and  newly  formed  connective  tissue  membrane  over  the 
entire  organ. 

_  Spleen.  Capsule  slightly  thickened  and  presented  numerous  adhe- 
sions, in  most  of  which  were  small  nodules.  Kidneys  showed  no 
special  changes.  The  mesenteric  glands  were  enlarged,firm,  whitish- 
gray  in  color,  a  few  of  them  slightly  pigmented.  Xo  caseation.  No 
tu!)ercles.  Small  intestines  showed  no  special  change.  In  the  rectum 
there  was  a  loss  of  substance  encircling  the  entire  bowel  with  nuich 
cicatricial  tissue  about  it  and  two  recent- looking,  deeper  ulcers  from 
which  apparently  the  hicniorrhage  had  come.  No  tuberculosis  of 
the  tubes. 

The  microsco])ical  examination  showed  the  liver  to  be  intensely 
amyloid.  The  tubercles  in  the  peritonetnii  were  composed  of  num- 
bers of  sub-miliary  nodules,  very  iibrous,  containing  few  cells  in  a 
firm  tissue.  In  the  middle  of  the  masses,  giant  cells  with  mural 
nuclei  and  fatty  granules:  no  caseation  in  the  nodules.  Tubende 
baciilli  were  very  al)undant. 

Tliis  case  presented  in  turn  many  points  of  interest  to  the  physi- 
cian, the  surgeon  and  the  pathologist.  In  the  first  place  it  is  a  good 
example  of  primary  tuberculosis  of  the  peritoneinn  ;  not  even  in 
the  pleura  or  pericardiinn,  both  of  which  showed  old  adhesive  inflam- 
mation, were  there  granidations,  and  a  most  rigid  search  failed  to  find 
tubercles  elsewhere.  Surgically,  the  operation  was  a  success  as 
the  symptoms  were  relieved,  the  general  health  improved  and  she  left 
the  Hospital  looking  and  feeling  well.  Then  the  accident  of  an  acute 
pneumonia  gave  an  opportunity  of  studying  the  condition  of  the  peri- 
toneum four  months  after  an  acute;  exacerbation  and  showed  the 
tubercles  undergoing  fibroid  change  but  still  retaining  their  charac- 
teristic structure  and  still  very  rich  in  bacilli. 

The  t)ther  case  illustrates  the  latency  of  peritoneal  tuberculosis  and 
the  I'xtent  which  it  may  reach  before  inducing  serious  symptoms. 

Case  IX. — Gradual  swcUim/  of  abdomen  ;  tumor  on  left  side.      Ova- 
riotomy.    Krtemive  tuhercnlar  peritonitis ;  recoDen/. 

Bridget  N.,  age  42,  admitted  to  the  gynax^ological  ward  October 
17th.     Married  19  years,  has  had  8  children.     Has  been  ill, 


IIP 
l! 


year!! 


on  and 


iphflMPTO 


38 

oft,  ever  amve  the  birth  of  her  last  child  5  years  ago.  Has  had  met- 
rorrhagia. She  has  had  successive  attm^ks  of  abdominal  swelling, 
and  within  the  past  year  has  noticed  a  lumi)  on  the  left  side,  which 
has  gradually  grown  larger,  and  it  is  for  this  she  sought  relief.  On 
inquiry  she  states  that  every  winter  she  is  apt  to  have  a  cough,  and 
has  had  pleurisy  on  the  right  side.  Her  mother  died  of  pulmonary 
hemorrhages.     Other  members  of  her  family  healthy. 

Dr.  Kelly  operated  October  18th  ;  i-enioved  a  tumor  of  the  left 
ovarv,  the  size  of  a  cwoanut.     On  the  right  side  the  ovary  was  as 
large  as  a  lemon,  cystic  and  the  tube  greatly  dilated.     The  ovarian 
tumor  and  the  entire  peritoneum,  visceral  and  parietal,  were  (u)ver(!d 
with  miliary  tubercles.    The  intestines  were  in  places  matted  together. 
There  were  500  cc.  of  fluid  in  the  peritoneum.    The  tubercular  nature 
of  the  growths  was  demonstrated  microscopically.    The  nodules  were 
firm  and  hard,  some  of  them  pigmented.     She  did  well  after  the 
operation  and  was  sitting  up  out  of  bed  by  the  6th  of  November, 
with  the  wound  perfectly  healed.     The  t(>m])erature  ranged  for  the 
first  ten  days  from  98°  to  100°.     After  the  28th  the  range  was  be- 
tween 98°  and  99.5°.     On  Dec.  18th  the  following  note  was  made  : 
"  She  has  gained  in  flesh  and  looks  well.     Tiic  abdomen  is  a  little 
distended  but  is  not  tender  and  there  are  no  signs  of  ett'usion.    There 
are  dullness,  nlles  and  feeble  breathing  at  the  base  of  the  right  lung 
where  she  has  had  pleurisy.     The  apices  of  the  lungs  are  clear." 
The  statistics  showing  the  results  of  this  operation  have  lately  been 
collected  by  several  writers,  particularly  Kuemmel '  and  Maurange.' 
This  last   writer  has  made  an  elaborate  analysis  of  the  cases   re- 
corded to  date,  seventy-one  in  all,  with  the  following  result :    There 
died  ailer  the  operation,  six ;  by  generalizaticm  of  the  tubercle,  seven ; 
there  recovered  sixteen  teases,  of  which  no  further  mention  than  this 
i^ct  was  made ;  fifteen  (-ases  were  alive  at  the  end  of  six  months, 
and  twenty-eisdit  cases  had  survived  a  year. 

Of  the  American  cases,  Maurangc  includes  those  of  Homans  (3), 
of  Van  der  Warker  (1),  Morrill  and  Bradford  (1),  Cabot  (2),  (ioodell 
(1),  and  Bruen  (1).  To  these  I  can  add  the  foD-wing  cases.  Goodell 
writes 3  that  he  has  operated  upon  four  cases,  in  i\V.  of  which  the 

1  Arohiv.  f.  klinische  Chirurgie,  1888.     Bd.  xxxvii. 

'  These  de  Paris,  1889.  "  P"vate  letter,  Nov.  28th,  1889. 


39 


0.  Has  had  met- 
lominal  swelling, 
e  loft  side,  which 
;oug;ht  relief.  On 
lave  a  cough,  and 
ied  of  pulmonary 
ly. 

tumor  of  the  left 
!  the  ovary  Avas  as 
;ed.  The  ovarian 
etui,  wei-e  (;overed 
2S  matted  together. 
>  tubercular  nature 

The  nodules  were 
iid  well  after  the 
3th  of  November, 
irc  ranged  for  the 
the  range  was  be- 
g  note  was  made  : 
abdomen  is  a  little 
of  ett'usion.  There 
!  of  the  right  lung 

lungs  are  clear." 
on  have  lately  been 
1 '  and  Maurange.^ 
s  of  the  cases  re- 
ana;  result :  There 
-he  tubercle,  seven ; 
•  mention  than  this 
nd  of  six  months, 

)se  of  Homans  (3), 
,Cabot(2),(;oodell 
ing  cases.  Goodell 
n  all.  of  which  the 


Nov,  28th,  1889. 


ascitic  fluid  was  recognized,  but  in  addition  ovarian  disease  was  sus- 
pected. In  none  of  the  ''ascs  were  the  tubes  or  ovaries  diseased.  So 
far  as  he  could  ascertain,  all  of  the  cases  got  well.  One  of  them, 
however,  after  six  months  excellent  health,  returned  w  itli  a  i)elvic 
tumor  and  ascites.  She  refused  an  operation  and  is  now  probably 
dead, 

Mundc  writes'  tliat  \w  has  operated  on  three  cases,  in  all  of 
which  there  was  as(!ites,  and  the  diagnosis  of  obscure  tumor  was 
made.  In  one  case  the  patient  recovered  Irom  the  operation  and  died 
two  months  later  of  pulmonary  disease,  wliicli  was  not  evident  at  the 
time  of  the  o])eration.  In  the  other  two  cases,  the  recovery  was  tem- 
jwrary  and  they  died  afterwards  of  exhaustion.  In  ail  three,  a 
distinct  abdominal  tumor  appeared  to  exist;  in  two  general,  in  tiie 
third  in  the  left  ovarian  region.  Thei-e  was  no  doubt  in  any  of  the 
cases  as  to  their  tuberculous  nature. 

Kelly  has  operated  upon  four  rases.-  The  first  case  was  in  1880, 
There  was  temptjrary  im])rovement.  Some  njonths  after  a  second 
operation  was  i)erformed.  The  patient  is  at  present  alive  and  w(!ll. 
The  operation  in  this  case  was  performed  for  tubal  disease  and 
peritonitis  was  found.  In  the  second  case  there  was  no  definite 
diagnosis  but  a  tumor  mass  was  evident.  An  encysted  pui-uJent 
peritonitis  was  found  which  was  drained.  Patient  recovered  tem- 
porarily and  died  one  year  afti'r  of  phthisis.  In  the  third  case,  the 
diagnosis  was  a  parovarian  cyst.  The  first  operation  was  in  May, 
1889.  The  al)donien  was  drained,  improvement  followed  for  a  time, 
but  the  fluid  re-aceumuiated  and  on  three  subsequent  occasions,  at 
intervals  of  about  six  weeks,  the  peritoneum  was  incis(!d  and  drained. 
At  the  last  operation  the  tube  and  ovary  of  the  right  side  were 
removed,  Tlie  patient  is  still  under  ol)servatiou  and  has  evidence  of 
some  fluid  remaining  in  the  peritoneum.  The  fourth  cacic  hits 
already  been  referred  to,  in  which  the  tubercular  disease  was  found 
as  an  acciderital  complication  with  an  ovarian  tumor. 

Homans' ^  fourth  case,  operated  upon  March  19th,  1889,  left  the 
Massachusetts  General  Hospital  in  June  (piite  well.  His  second  case, 
included  in  Maurange's  statistics,  operated  upon  April  20th,  1887 — 
referred  to  at  page  44  of  his  statistical  account  of  three  hundred  and 


:ii:;l 


■n 


'  Private  letter,  Nov.  IStli,  1889. 
*  From  notes  given  by  Dr.  Robb. 


'Private  letter,  November,  l88!). 


1. 


,  t 


-   I  -«  p  I  - 


II  f 


h  .J- 


40 

forty-four  laparotomies'— is  of  great  interest,  as  Dr.  Cutler  examined 
the  peritoneal  growth  and  found  it  to  be  tubercular.  In  :May,  1889, 
more  than  two  years  after  the  operation,  she  remained  perfectly  well. 

Two  eases  operated  upon  by  Gardner,  of  Montreal,  have  already 
been  referred  to  in  previous  sections  of  this  paper  (pp.  80,  83.) 

H.  P.  C.  Wilson,  of  Baltimore,'^  has  operated  upon  one  ease  in 
which  the  disease  was  thought  to  be  a  cystic  ovarian  tumor.  The 
entire  peritoneum  was  studded  with  miliary  tubercles.  The  patient 
recovered  from  the  operation  but  died  six  months  attcrwai'ds. 

Dudley,  of  Chicago,^  operated  upon  one  case  in  1884.  There  was 
d(juble  ovarian  disease  as  well.  She  recovered  but  a  fistula  remained. 
Death  occurred  in  1 888.    G.  E.  Shoemaker '  reports  a  case  of  recovery. 

To  these  t-ases,  tor  statistical  i)urposes,  may  be  added  the  four 
reported  by  S])aeth,'  as  they  are  not  referred  to  in  :\Iaurange's  paper. 
Of  these,  one  died  after  the  operation ;  the  second,  three  months  after 
of  acute  phthisis;  the  third,  four  months  after  of  tuberculosis  of  the 
intestines,  and  the  fourth,  at  the  time  of  report,  had  intestinal  disease. 
M.  Schmidt*'  has  reported  two  cases,  one  of  which  recovered  com- 
pletely and  was  well  more  than  a  year  after  the  operaticm,  the  second 
was  benelited  temporarily  but  death  occurred  five  mcjiiths  after. 
Imlach^  states  that  he  has  had  five  cases,  all  of  which  had  resulted 
in  api)arent  cure. 

( )f  these  additional  twenty-six  cases,  the  results  cannot  be  said  to  be 
on  the  whole  so  satisfiictory,  as  fourteen  cases  were  dead  at  the  time 
of  the  report,  one  of  an  intercurrent  pneumonia. 

The  majority  of  writers  on  the  subject  speak  hopefully  of  the  oper- 
ation in  suitable  cases,  and  from  what  we  know  of  the  natural  history 
of  the  disease  and  from  a  study  of  the  cases  in  which  laparotomy  has 
been  performed,  whether  specifically  for  tubercular  disease,  or  by  acci- 
dent, w^e  may  regard  it  as  not  only  justifiable  but  urgently  indicated 

in  many  cases. 

Secheyron^  concludes  from  an  analyses  of  forty-two  <'ases  of  lapa- 

'  Boston.     Sawyer  &  Sons,  1887.  '' Private  letter,  Nov.  llth,  1889. 

3  American  .Journal  of  Obstetrics,  Nov.,  1889. 
♦Medical  and  Surgical  Reporter,  April  13th,  1889. 

s  Loc.  cit.  "  Centralblatt  f.  Gyniicologie,  1889,  No.  32. 

'  British  Med.  .lournal,  Dec.  14,  1889. 

sNouvelies  Archives  d'Ohst/.trique  et  de  Gynecologie,  No.  11,  1887,  quoted  in 
American  Journal  of  Obstetrics,  Vol.  21,  p.  447. 


41 


Dr.  Cutler  examined 
lar.     InMay,  1S81), 
lained  perfectly  well, 
lutreal,  have  already 
;r  (pp.  80,  83.) 
id  upon  one  ease  in 
varian  tumor.     The 
•ercles.     The  patient 
IS  att(>rwards. 
in  1884.     There  was 
Lit  a  fistula  remained, 
rts  a  ease  of  rec;overy. 
•  be  added  the  four 
in  INlaurango's  paper, 
d,  three  months  after 
)f  tuberculosis  of  the 
lad  intestinal  disease, 
hich  recovered  com- 
op(>ration,  the  second 
1   live   months  after. 
['  which  had  resulted 

ts  cannot  be  said  to  be 
^ere  dead  at  the  time 

lopefully  of  the  oper- 
of  the  natural  history 
ivhieh  laparotomy  has 
lar  disease,  or  by  acci- 
)ut  urgently  indicated 

rty-two  cases  of  lapa- 

ir,  Nov.  11th,  1889. 

macologie,  1889,  No.  32. 
',  No.  11,  1887,  quoted  in 


rotomy,  that  interference  is  not  called  for  in  the  acute  or  chronic  dis- 
ea.se  when  generalized,  whether  with  or  without  sero-pnritlent  effu- 
sion, and  thinks  that  the  operation  is  only  called  for  when  symptoms 
of  strangulation  or  of  jjcrforation  of  the  intestines  appear.  lie 
acknowledges  that  encysted  tubercular  peritonitis  calls  for  surgical 
intervention  as  the  (-ondition  is  really  one  of  cold  abscess. 

Spaeth,  too,  does  not  write  very  encouragingly,  but  in  a  disease 
heretofore  believed  to  be  incurable  the  statistics  of  Maurantre  show 
such  a  percentage  of  recoveries,  that  wc  may  place  the  operation 
among  the  triumphs  of  recent  surgery. 

Two  questions  remain  for  consideration,  what  cases  are  most  suit- 
able for  (operation,  and  how  can  we  explain  the  beneficial  influence? 

Undonbtcdly  the  cases  of  the  first  group,  those  with  fresh  eruption 
and  considerable  effnsion,  whether  free  or  sacculated,  offer  the  best 
chance  of  recovery,  as  the  disease  is  more  likely  to  be  primary  in  the 
peritoneum,  the  general  condition  is  usually  better,  and  the  subse- 
quent chances  of  general  infection  are  much  slighter.  When  the 
Fallopian  tubes  are  extensively  diseased,  and  when  the  j)rocess  has 
extended  through  the  diaphragm  to  the  pleura,  the  (condition  is  of 
course  less  favoi-able.  The  e::istence  of  marked  omental  tumor,  in 
the  form  of  a  ti-ansverse  ridge,  need  not  necessarily  be  an  objection  to 
operation,  as  we  have  seen  that  in  two  of  (xairdner's  cases,  si)onta- 
neous  resolution  of  snch  ma.ssestook  place.  In  cases  then  with  some- 
what sudden  onset,  rapid  development  of  ascites  with  fever  of  mod- 
erate grade,  we  may  be  most  sanguine  of  sncccss. 

In  the  class  of  i-ases  with  extensive  ctiseous  masses  in  the  perito- 
neum and  a  purulent  exudation,  the  outlook  is  necessarily  less  hope- 
ful, but  even  in  such  instances,  particularly  when  the  exudation  is 
sacculated,  la})arotomy  may  be  advised  as  a  palliative  measure. 

In  the  chronic  adhesive  form,  no  benefit  could  be  expected  to  fol- 
low the  operation,  which  could  (^idy  be  intended  to  remove  an  omen- 
tal mass  or  to  oj)en  a  sacculated  effusion.  In  the  majority  of  the 
cases  of  this  group  nature  is  effecting  a  cure  in  which  she  scarcely 
needs  outside  assistance ;  and  the  danger  lies  not  so  much  in  the 
peritoneal  disease  as  in  the  risk  of  pulmonary  affection. 


If 


i|: 


18 


It  is  difficult  to  exjJain  the  beneficial  results  of  the  operation.     It 
interesting  to  note  that  not  alone  in  tubercular  {xjritonitis,  but  i 


in 


42 


other  forma  with  effusion,  the  simple  opening  and  drainage  of  the 
cavity  has  seemed  to  exereise  a  very  benefieial  effect  on  the  subsequent 
course  of  the  disease.  Tims,  Homans  reports  a  case'  in  which  an 
exploratory  laparotomy  was  performed  in  a  woman,  aged  sixty,  with 
enormous  ascites:  Forty  pounds  of  fluid  were  n-moved  and  a  soft 
tumor  was  found  attached  to  the  sacrum  and  right  ilium  The  abdo- 
men was  sponged  out  and  sewed  uj),  as  it  was  found  impossible  to 
remove  the  tumor.  The  i)atient  i-ecovered  rapidly,  was  greatly 
relieved  and  the  fluid  never  re-accumulated.  Death  occurred  a  ye^r 
subse(piently,  and  at  the  auto])sy  a  sarcoma  was  found  fdling  the 
pelvis.  This  would  indicate  that  the  thorough  drainage  of  an  ascites, 
even  of  enormous  extent,  may  so  alter  the  condition  of  the  pcritonenm 
that  the  fluid  is  not  re-formed.  More  remarkable  still  are  the  eases 
which  indicate  that  the  mere  opening  of  tlie  al)dominal  cavity  modifies 
in  some  way  the  develojiment  of  new  growths.  Gairdner  states"  that 
Sir  Spencer  Wells  informed  him  of  a  case  of  apparently  cancerous 
peritonitis,  in  which,  after  an  exploratory  incision,  the  symptoms 
subsided  and  the  woman  got  well.  Mr.  Lawson  Tait^  comments  at 
some  length  on  this  remarkable  tendency  of  abdominal  neoplasms  to 
undergo  retrograde  changes  after  an  exploratory  incision. 

His  statements  on  this  point  are  most  interesting  and  deserve  the 
careful  consideration  of  physicians  as  well  as  surgeons.  He  says 
that  he  has  seen  tumors  disa])pear  atler  laparotomy  in  cases  of  dis- 
ease of  the  liver,  spleen  and  head  of  the  pancreas.  He  does  not 
specifically  mention  cancer  of  the  peritoneum.  His  remarks  deserve 
quoting,  as  they  bear  directly  upon  this  subject. 

"The  cases  are  far  too  numerous,  and  the  results  indicate  se- 
quence far  too  clearly,  for  us  to  dismiss  the  phenomena  as  a  mere 
coincidence ;  nor  can  we  accept  the  explanation  of  subsequent 
medical  treatment  as  having  brought  about  this  much-desired  ending. 
I  am  satisfied  that  the  mere  opening  of  the  peritoneal  cavity  has  a 
direct  influence  in  setting  up  the  process  of  absorption  of  the  tumor, 
and  my  ectnviction  in  this  direction  lias  increased  my  confidence  in 
the  principle  of  exploration.  That  some  emphatic  physiological 
change  is  at  once  set  up  by  opening  the  peritoneal  cavity  is  clearly 

» Loc.  cit.,  page  40.  *  Loc.  cit.,  page  46. 

•Edinburgh  Medical  Journal,  Nov.  and  Dec,  1889. 


43 


11(1  drainage  of  the 
•t  o»  the  siibseqiiont 
1  case '  in  which  an 
an,  aged  sixty,  witli 
•cniovcd  and  a  soft 

ilium  The  alido- 
ound  impossible  to 
pidly,  was  greatly 
ath  occurred  a  ye^r 
IS  found  filling  the 
ainage  of  an  ascites, 
in  of  the  peritoneum 
>lc  still  are  the  cases 
linal  cavity  modifies 
Jairdncr  states'"  that 
pparciitly  cancerous 
sion,  the  symptoms 

Tait^  comments  at 
)minal  neoplasms  to 
incision. 

ng  and  deserve  the 
surgeons.  He  says 
my  in  cases  of  dis- 
reas.  He  does  not 
lis  remarks  deserve 

results  indicate  se- 
enomena  as  a  mere 
tiou  of  subsequent 
luch -desired  ending, 
itoneal  cavity  has  a 
ptiou  of  the  tumor, 
d  my  confidence  in 
)hatic  physiological 
ml  cavity  is  clearly 

ge  46. 


i 


indicated  by  the  uniform  onset  of  a  most  distressing  thirst,  which 
lasts  (or  days,  and  is  not  seen  so  markedly  after  any  other  operation 
known  to  me.  lict  the  incision  in  tiie  abdominal  wall  l)e  made  down 
to  the  peritoneum,  but  let  the  serous  envity  remain  unopened  and 
this  thirst  is  not  marked.  15ut  let  the  peritoneum  be  opened  but  a 
finger's  breath  and  the  result  is  marked.  Tliat  a  tlieraiieufie  change 
is  effected  in  tiie  peritoneum  itself  by  the  mere  opening  of  the  cavitv 
is  now  universally  recognized  in  the  treatment  of  what  we  call  tuber- 
cular peritcmitis  by  abdominal  sei^tioii.  I  have  now  had  a  large 
experience  on  this  ])oint,  and  can  say  ])ositively  that  we  can  cure 
permanently  and  spoe<lily  eases  that  have  gone  even  as  far  as  sup- 
puration, by  o|iening  and  cleansing.  Hut  in  the  bad  eases  in  all 
probability  the  cleansing  is  never  e(miplete,  no  matter  how  much 
time  and  care  are  spent  on  it.  And,  in  the  non-purulent  cases,  I 
very  oflen  do  no  cleansing  at  all,  but  merely  empty  out  the  serum 
and  put  in  a  <lrainage-i)ipe.  Yet  the  great  majority  of  these  cases  are 
cured  by  these  simple  means." 

Evidently,  in  whatever  way  brought  about,  the  opening  and  drain- 
age of  the  peritoneum  favors  in  a  remarkable  way  the  regression  of 
the  tubercles  ;  and  it  does  more  than  this,  foi-,  a.s  has  been  frequently 
noted  and  as  is  well  indicated  in  the  history  of  Case  VIII,  with 
an  improvement  in  the  local  symptoms  the  fever  reduces  and  the 
general  condition  of  the  patient  I'apidly  improves.  In  some  way 
the  operation  renders  the  (;onditi(jn  of  the  peritoneum  moi-e  favorable 
to  the  fibroid  changes  by  which  alone  healing  is  induced. 

There  are  on  i-ecord  several  cases  from  which  we  may  get  an  idea  of 
the  condition  of  the  peritoneum  some  months  after  the  operation.  The 
case  of  Emma  (},,  so  often  referred  to,  is  pi'obably  as  good  an  example 
as  could  be  obtained  of  liealing  tuberculosis.  The  effusion  had  disap- 
peared, in  the  neighborhood  of  the  liver  the  adhesions  had  become 
fibroid,  the  tubercles  were  hard  and  pigmented,  and  there  was  no- 
where any  congestion  about  them.  In  the  literature  there  are 
several  cases  of  this  kind.  Thus,  Hirschberg^  narrates  the  case  of 
a  woman  upon  whom  laparotomy  was  performed  for  peritoneal 
tuberculosis,  and  in  whom  the  abdominal  symptoms  subsided  com- 
pletely. Eight  months  af\er,  the  patient  died  of  phthisis,  and  there 
were  no  traces  of  the  numerous  granulations  which  had  existed  on 

'  Quoted  by  Kiiemmel.     Loc.  cit. 


:| 


-Jl      l! 


'J  J 


J 

i 

Pill'- 

1  i 

1   " 

;. 

j; 

■ : 

i    : 
1    \ 

t  ; 

jr': 

V 

44 

tlio  nicmbranc  at  the  time  o/  tho  opcraticn.  Anotlior  case,  also 
quoted  Ia-  Kiicimncl,  a  \(\v\  a^^cd  J7  witli  ascites  and  tuboivles  in 
the  |>eritoneiim  died  six  mouths  after  the  operation,  The  autopsy 
showed  that  the  effusion  had  not  l»een  reju'odueed  and  that  lieaiing 
had  occurred. 

A  third  ease  of  Ahlteld's'  is  still  more  interesting,  in  wliidi  ho 
found,  diirini;'  the  perfornianee  of  Freund's  operation,  the  [)eritoneum 
eovered  with  }rranuhition.s.  At  the  aut(tpsy,  a  year  and  a  halt'  after- 
wards, there  was  no  trace  of  the  tubercles. 

iSovcral  views  have  been  advanced  in  r'xphunition  of  the  beneficial 
effects  of  the  operation.  Thus,  Cameron,  of  Iluddersfield,  thinks 
that  the  curative  action  is  due  to  the  removal  of  the  ptomaines  which 
aceiimidato  in  tiie  ascitic;  fluid  and  the  absorption  of  which  is  res])un- 
sible  for  the  constitutional  disturl;ance.  I'ossibly  it  may  be  by  a 
reduction  in  the  activity  of  the  inflamraator.  ])rocesses  about  the 
tubercles,  wliich  some  have  sup[)osed  are  kept  up  and  eneourajied  by 
the  ascitic  fluid,  but  it  is  more  reasonable  to  su])pose  the  existence  of 
the  latter  to  depend  upcm  the  activitv  of  the  former.  I  scarcely 
think  we  are  at  pres(Mit  in  a  position  to  give  a  thoroughly  acceptable 
explanation  why  incision  and  drainage  should  in  thes(^  cases  of 
tubercular  and  other  neoplasms  so  remarkably  inhibit  the  growth 
and  often  induce  retrograde  curative  changes. 

Are  all  oi  ihese  cases  of  cure  truly  tubercular  ?  Spaeth"  raises  this 
question  and  throws  doubt  upon  the  diagnosis  in  the  absence  of  the 
proofs  afforded  by  the  discovery  of  the  bacillus,  or  the  infective  nature 
of  the  growths  as  demonstrated  by  inociulation.  I  cannot  see  that  in 
practice  this  is  an  entirely  forcible  objection  ;  for,  as  a  rule,  the  peri- 
toneum is  the  seat  of  miliary  and  nodular  growths  in  only  two  affec- 
tions, cancer  and  tubercle — the  former  a  very  rare,  the  lattei-  a  very 
common  occurrence,  and  without  histological  examination,  it  may  be 
impossible  in  certain  (aises  to  say  which  of  the  two  conditions  is  be- 
fore us. 

Spaeth  makes  the  interesting  statement  that  there  are  numerous 
ca.ses  of  other  chronic  diseases  of  the  peritoneum  which,  at  first  glance, 
look  like  tuberculosis,  but  which  on  examination  prove  to  be  simply 
chronic  peritonitis  with  nodular  thickenings  or  lymphoraatous  growths. 

'  Quoted  by  KuemnieJ,  from  Deut.  med.  Woch.,  1880.  *  Loc.  cit. 


notlicr  case,   also 

iiiid  (iiluM-flcs  in 

»ii.     'Pile  autopsy 

and  tliat  licaling 

iii}f,   in   wliitli  ho 

>ii,  tlic  pc'iiloiu'iim 

and  a  hall'  uf'ter- 

II  of  tlie  bi'iioticial 
(Idorsficld,  thinks 
'  ptomaines  which 
t"  wliich  is  rospou- 
V  it  may  bo  by  a 
•ocosses  about  the 
ind  onoourajjjed  by 
so  the  existence  of 
rmer.  I  scarcely 
oughly  acceptable 
in  these  cases  of 
nhibit  the  growth 


Spaeth^  raises  this 
he  absence  of  the 
le  infective  nature 
(jannot  see  that  in 
IS  a  rule,  the  peri- 
in  only  two  affec- 
(,  the  latter  a  very 
i nation,  it  may  be 
0  conditions  is  be- 

lere  are  numerous 
ich,  at  first  glance, 
jrove  to  be  simply 
horaatous  growths. 

*  Loc.  cit. 


i 


My  colleague,  Dr.  Welcli,  iiif<.rms  me  that  his  experience  coincides 
witli  this,  and  thai  there  is  a  form  ..f  chronic  peritonitis,  usiii.liv 
a.>^sooiated  with  nnieh  olliision,  in  which  the  p<>ritoneiim  is  studdeil 
with  fibroid  or  lymphomalons  nodides.  lb'  has,  in  Flint's  Practice 
(Otli  Edition,  iSM(i),  de,-cribcd  these;  nodules  as  occurring  in  chronic 
serous  ])eritoiiitis  luid  speaks  of  the  didicidty  in  the  diagnitsis  l)e- 
tweeii  this  condition  and  liil)ercular  peritonitis. 

The  point  is  one  not  often  referred  to  l)y  patholdgists. 

Birsch-JIirschfeid  '  speaks  of  fine  libroiis  nodules  occurring  in 
large  lunnbers  on  the  peritoneum  in  chronic  iuHammation,  similar 
to  those  wliieh  are  seen  U})on  the  jjlcura. 

Kokitansky,-  t(M),  speaksof  papillary  fibrous  growths  of  sub-serous 
connective  tissue  as  a  result  of  hyperiL-mia  of  the  peritoneum. 

IVochownick,''  in  a  paper  upon  la|)arotomy  in  chronic  peritonitis, 
has  some  very  interesting  observations  upon  this  subject.  Two  of 
his  five  cases  wort;  regarded  as  tuberculous  until  an  examination  was 
made.  In  the  first  case  there  were  two  elastic  tumors  by  the  side  of 
the  uterus.  At  the  operation  extensive  union  of  the  omentum  with 
the  pelvic  peritoneum  was  found.  There  was  a  hemorihagic  etliision. 
The  tumors  were  made  up  of  encysted  exudation.  Over  the  intes- 
tines there  was  a  grayish  gramdar  deposit.  Although  he  states  that 
this  was  regarded  as  tuberculosis,  I  do  not  see  that  he  mentions  the 
existence  of  any  tuberde-like  granulations  or  nodules.  The  exami- 
nation of  portions  removed  from  the  omentum  showed  that  tubercles 
were  not  present,  and  it  was  evidently  a  case  of  simple  peritonitis. 
A  second  case,  much  mor(>  remarkable,  occurred  in  a  girl  of  sixteen 
years,  with  a  well-marked  tumor  in  the  left  side  of  the  abdonuMi, 
which  upon  operation  was  found  to  1k>  cuimposed  of  the  coil  of  intes- 
tines. The  entire  peritoneum  was  covered  with  hundreds  of  small 
nodular  tumors.  On  examination  these  were  fi)und  to  be  made  up 
of  a  lymphoid  tissue,  chiefly  seen  at  the  outer  margin  of  the  nodules, 
the  centres  of  which  had  in  many  places  undergone  softening. 
Munde  was  present  at  the  operation  in  this  case  and  refers  to  it 
(American  Journal  of  Obstetrics,  Vol.  19,  page  8!»9)  as  one  of 
multiple  carcinositi  of  the  parietal  and  visceral  peritoneum.    The 

'  Lehrbiu'h  dei  Pathologische  Anatomie,  2te  Aufiiige. 

'^  3te  Auflage,  Bd.  3,  p.  13S. 

^Deutsche  med.  Wochensclirift,  1889,  Number  24. 


M 


1J 

( 

T    » 

il: 


^i 


III 

Ft  I : 


15 


I 


i     -11: 


1 

i       ': 

r 

i 

1 

1 

i 

'. 

,   i 

i 

il 

m 

V     i 


ii    ' 


46 

patit'iit,  it  may  Ih'  mciitioiitHl,  made  a  nipi*!  rciovi'i-v,  hut  I  s(m>  iio 
nnU'  as  tn  tlic  siil)s('(|U<Mit  history. 

J.  F.  I'avnc'  (IcHcrilM's  a  caHcorinimitc  lihroiis  liraiiiihitions  of  the 
pcritoiuMiin  assdciatcd  with  disscmiiiatcd  --rowtlis  thntuj-hdiit  tlic  liver, 
p()s.sihly  syphilitic,  and  lihn.us  thickcnin'^  of  th(«  walls  i.f  tin'  pnrtul 
voin  and  hile  duct.  The  patient,  a  man,  aj?od  52,  was  admitted  to 
St.  Mary's  II(.spital  nnch'r  tlic  care  of  Sir  Edward  Sicvckinff  and 
died  witii  synipt(mis  of  dropsy.  The  |)eritoM('nm  was  covered  over 
with  miliary  <rranulations  witliout  any  hirirer  nodules  and  without 
general  thickcnin^f  or  adhesion.  There  were  a  few  litres  of  fluid  in 
the  cavity.  Payne  remarks  that  the  peritoneal  <j;ranulations  were 
<!ertainly  not  like  caix-er,  tubercle  or  any  f>;eneraHzed  jrrowth  which 
cominonlv  (Mcnrs  in  the  form  of  a  miliary  eruption.  They  were 
essential  Hhrous  ont^jrowths  of  the  peritimeum  and  not  of  its  serous 
epithelium.  Me  says  they  resemble  somewhat  the  fibrous  outgrowths 
met  with  in  the  capsule  of  the  liver  or  spleen. 

I  have  never  seen  ca.ses  of  this  kind,  unless,  indeed,  as  is  possible,  T 
have  mistaken  some  of  these  eases  for  fibroid  tubercles.  On  the  other 
hand,  it  is  e(iually  possible  that  those  who  have  described  these  cases 
of  chronic  nodular  peritonitis,  nuvy  have  confounded  this  condition 
with  the  healed  tubercular  disease.  Indeed,  in  reference  to  Emma 
G.,  Case  VTTI,  Dr.  Wck-h  tdls  me  that  had  not  Dr.  Councilman,  at 
the  date  of  the  opei'ation,  examined  the  nodules  removed  and  demon- 
strated their  tuberculous  nature,  he  v  ould,  at  the  auiopsy,  which 
occurred  four  and  a  half  months  subsequently,  scarcely  have  regarded 
the  nodules  as  tubercular,  so  hard  and  fibroid  had  they  become.  In 
this  respect  the  case  is  one  of  the  greatest  importance,  as  it  shows  how 
essential  the  examination  of  the  nodules  is,  taken  fresh  at  the  time  of 
the  operation. 

[t  must  not  be  forgotten  that  in  certain  cases  the  bacilli  are  very 
difficult  to  find  in  peritoneal  tuberculosis,  though  they  may,  as  in 
the  ease  just  referred  to,  he  most  abundant  even  when  the  tul)ercles 
are  very  hard  and  fibroid.  In  all  cases,  when  possible,  the  inocula- 
tion of  a  rabbit  or  guinea  pig  should  supplement  the  hist(  .logical 
examination. 

The  important  practical  point,  however,  is  the  relief  and  cure  of 

'  Transactions  of  tfie  Pathological  Society  of  London,  Vol.  xxi. 


)vt.'rv,  l)ut  I  stH*  IK) 

li'raniilatioiiM  nf  tlio 
liroiifi'lioiit  the  liver, 
walls  nt'  the  portiil 
2,  was  adinittcil  to 
anl  Sicvckiii;;'  and 
II  was  covered  (tver 
iiditleH  and  witlioiit 
L'W  litres  of  Hiiid  in 
•rraiudatiniis  were 
lized  ifi'owtli  whieii 
i|»tion.  They  were 
nd  not  ol"  its  serous 
•  Hlirons  oiitfirowths 

Iced,  as  is  possible,  T 
reles.  On  the  other 
:les(!ribed  these  eases 
nde<l  this  condition 
reference  to  Kninia 
Dr.  Coiineilinan,  at 
enioved  and  demon- 
the  autM[)sy,  which 
areely  have  regarded 
id  they  heeome.  In 
mee,  as  it  shows  how 
1  fresh  at  the  time  of 

i  the  i)aeilli  are  very 
igh  they  may,  as  in 
when  tlie  tul)ercles 
jossible,  the  inocnhi- 
lent  the  histological 

lie  relief  and  cure  of 

ol.  XXI. 


47 

these  cases  by  laparotomy,  and  tlie  8nrg(.ons  mav  well  leave  to  the 
pathologist  the  minor  question  of  determining  the  natm-e-whcther 
fii.roid,  lymphoniatons  or  tuher.-uiar-of  the  ehnmic  peritonitis 

Am<,ng  the  conclusions  which  follow  from  the  foregoing  consider- 
ations, are  : 

_  First,  that  tubercular  peritonitis  is  often  a  latent  affection,  local- 
ized HI  the  peritoneum,  which  may  even  run  its  course  without  in- 
ducing  special  symptoms. 

Second,  that  as  in  other  local  tubercular  processes  there  is  in  this 
a  natural  tendency  to  healing,  which  takes  place  more  frcuu-ntly  than 
has  lutherto  l)een  supposed. 

Tliird,  that  statistical  evidence  shows  laparotomy  to  be  in  many 
cases  a  palliative,  and  in  a  certain  number  a  (;urative,  mea.sure. 


}• 


l'/ 


A. 


I.)» 


14 


f< 


t  < 


p 


'151  i 


'III 


III 


c  vn 


ACUTE  NEPHRITIS  IN  TYPHOID  FEVER. 
By  WI(  ;  lAM  OSLER,  M.  D, 

Occurring  early  in  the  course  of  typhoid  fever,  nephritis  and  pneu- 
monia are  very  apt  to  cause  error  in  diagnosis,  and  too  often  the 
post-mortem  examination  gives  tlie  first  intimation  that  there  has 
been  a  general  disease,  masked  entirely  by  prominent  local  symptoms 
in  lungs  or  kidneys.  There  are  few  ])hysicians  who  luive  not  puz- 
zled over  these  cases  of  so-called  pneumo-tyjihoid  and  nepln'o-ty[)hoid 
and  have  been  undecided  whether  they  had  been  dealing  with  a  pneu- 
monia or  an  acute  nephritis  with  adynamic  symptoms,  or  whether 
the  disease  has  not  been  typhoid  fever  with  early  and  unusually  well 
marked  pulmonary  or  renal  lesions. 

In  my  experience,  the  cases  of  typhoid  fever  which  have  set  in 
with  lobar  pneumonia,  and  in  whicli  the  symptoms  of  this  disease 
have  dominated  the  entire  course,  have  been  more  common  than  those 
in  which  nephritis  was  a  com])licatiou.  The  latter  is  by  no  means 
frequent,  and  du;  ing  the  ten  years  in  which,  as  pathologist  or  phy- 
sician, I  was  connected  with  the  Montreal  General  Hospital — one  of 
the  largest  fields  for  the  study  of  typhoid  fever  on  this  continent — 
I  do  not  remember  to  have  seen  an  in&tance  of  the  kind. 

The  renal  complications  which  we  meet  with  in  typhoid  fever  may 
be  grouped  as  follows :  first,  febrile  albuminuria,  usually  not  of 
much  moment,  even  thougli  casts  be  present ;  second,  acute  nephritis, 
often  hemorrhagic,  which  sets  in  early  and  which  gives  the  promi- 
nent clinical  features  to  the  case  ;  third,  a  late  nephritis,  occurring 
during  convalcsi-eucc  and  whicli  is  analogous  to  that  wiiich  follows 
other  infectious  disorders;  fourth,  a  lyniphomatous  (Wagner)  nephri- 
tis, also  occurring  late ;  and  lastly  may  be  mentioned,  as  the  ui'inary 
symptoms  are  well  marked,  a  post-typhoid  pyelitis. 

Of  these,  the  second,  acute  nephritis — the  aephro-tijplius  of  the 
Germans,  the  Ji^vix  tt/p/toi<(e  Cl  fonae  renale  of  the  French — occur- 

1 


jf.t  J 


ring  at  the  onset  or  quite  early  in  the  disease,  is  es]5ecially  Iil«.ly  to 
cause  difficulty  in  diagnosis  and  forms  a  serious  complication. 

The  following  cases  illustrate  many  of  the  clinical  features  of  this 
oonditit)n. 

Ca8E  \.—  On.d  with  rigor.  Prr.isfent  high  fever.  Haimoqlohimiria 
w,th  nJhnmen  and  tuhe  rash.  Delirium.  HymptomH  of  perfora- 
tioiK  Death  on  the  Uth  day  of  illness.  Typhoid  lesions  in  Uemi; 
perforation .     Xephritis. 

John  T.,  aged  120,  oysterman,  colored,  admitted  to  the  Johns  Hop- 
k.ns  Hospital,  June  11th,  18«f),  complaining  of  pain  in  the  lumbar 
and  hy])oclH.ndriac  regions,  with  cough  and  shortness  of  hreath  He 
had  I.cen  ill  since  the  5th,  when  hecaught  a  heavy  .-old  and  had  pain 
in  the  hack,  chest  and  limbs,  and  from  the  description  he  must  have 
had  a  severe  rigor.  Though  libeling  miserable  he  kept  at  work  until 
the  10th,  the  day  before  his  admission.  He  says  that  he  has  eaten 
nothing  for  three  days. 

On  admission,  he  was  complaining  of  lightn(>ss  of  the  head  and 
pain  ,n  the  back.  Temperature  was  104°.  Pulse  84,  strong  and 
full,  kespirations  38,  shallow.  The  tongue  was  dry  and  brown  • 
the  skm  very  hot  and  dry.  He  coughed  very  frecpiently  and  expec- 
torated slightly  blood-stained  naicus.  The  abdomen  was  not  dis- 
^nded;  .t  was  a  little  tender  to  the  touch  in  the  right  iliac  region. 
Ihe  lungs  and  heart  were  normal. 

He  was  ordered  antipyrin-5  grs.-and  to  be  sponged  every  three 
aoursand  given  a  fever  mixture;  and,  if  the  temperature  reached 
lOo  ,  to  1)6  given  a  graduated  bath. 

12th.— Passed  a  restless  night.  Temperature  at  9  a.  m  102° 
Cough  troublesome  and  expectoration  slightlv  tinged  with  blood' 
E.^im.nat.on  of  the  lungs  negative.  The  condition  of  the  urine  was 
as  follows  :  Amount  passed  about  500  cc. ;  dark  reddish  brown  in 
color;  acid  111  reaction  ;  moderate  amount  of  grevish  sediment  •  spe- 
cific gravity  1024 ;  albumen  present.  Microscopical  examination 
showed  numerous  epithelial  and  granular  casts,  and  much  granular 
ael)ris  ;  no  blood  corpuscles. 

Towards  evening  the  temperature  rose  again  to  105°  and  was  re- 
duced by  a  graduated  bath. 


13th. — Patient  passed  a  restless  night.    Tr 


mperature  between  104"^ 


ecially  likdy  to 
►ligation, 
features  of  tliis 

laimoglohinuria 
oms  of  perfora- 
esions  in  ileum  ; 

he  Joiins  Hop- 
in  the  lumbar 
Dfhroath.  He 
d  and  ]iad  pain 
1  he  must  have 
t  at  work  until 
t  he  has  eaten 

the  head  and 
S4,  strong  and 
y  and  bi-own  ; 
tly  and  oxpec- 

was  not  dis- 
it  iliac  region. 

'd  every  three 
•atnrc  reached 

a.  m.  102°. 
I  with  blood, 
the  urine  was 
ish  brown  in 
^diment ;  .spe- 

examination 
luch  granular 

and  was  re- 

between  104° 


and  105°.  He  had  a  liquid  and  slightly  blood-stained  stool.  He 
was  conscious;  pulse  110,  dicrotic.  Tongue  dry.  Examination 
of  the  abdomen  negative.  The  blood  was  examined  on  several 
occasions  with  negative  result.  The  urine  presented  the  same  char- 
acteristics, but  was  perhai)s  a  little  higher  in  color. 

14th. — Temperature  at  9  o'clock  104.4°.  Patient  did  not  seem  so 
well ;  was  dclirous  ;  passed  urine  involuntarily. 

15th. — Temperatiu-e  again  105°,  reduced  by  a  graduated  bath  to 
102.4°.  Urine  presented  the  same  dark  color  ;  specific  gravity  1022, 
acid  in  reaction ;  numei'ous  tube  casts,  no  red  blood  corpuscles ; 
abundant  hicmoglobin. 

16tli. — Temperature  lower,  not  reaching  104°.  Pat'ent  conscious  ; 
pulse  1(14,  no  longer  dicrotic.  Tongue  swollen  and  moist,  uniformly 
furred.  Abdo  leu  not  distended,  soft,  no  tenderness,  a  little  gurgling 
in  the  r'  >  iac  fossa.  Splenic  dullness  began  at  the  lower  border  of 
the  7ti!  -' .'Xtended  four  finger's  breadth  vertically.  Edge  not  pal- 
pable. Heart  sounds  clear.  Exuniimition  of  the  lungs  negative.  700 
ounces  of  urine  passed  in  the  24  hours  ;  pecific  gi'avity  1018  ;  color 
deep  blood  red.  It  contained  albumen,  granular  and  epithelial  casts, 
hiomoglobin,  but  no  blood  corpuscles. 

17th. — Temperature  uot  above  103°.  Passed  a  very  comfortable 
night;  was  dclirous  at  times.  Pulse  120.  Tongue  moist  and 
furred.  Conjunctiva}  a  iittle  jaundiced.  Abdomen  not  distended. 
Heart  sounds  clear.  Urine  cherry  red,  not  quite  so  dark  but  con- 
tained a  larger  amount  of  sediment ;  specific  gravity  1016. 

18th. — Patient  seems  better.  He  complained  of  pain  in  the 
abdomen  for  which  he  was  ordered  a  turpentine  stupe.  In  the  even- 
ing, at  9.30,  he  had  a  rigor.  Tlie  temperature  fell  to  97°,  but  after  the 
chill  it  rose  again  to  102°.  Between  8  and  11  o'clock  he  had  four 
loose  stools.  The  abdomen  became  very  painful  and  a  little  swollen. 
At  3  a.  ra.  the  temperature  was  104°.  There  was  great  pain  in  the 
abdomen.  There  was  no  special  distension.  At  7  o'clock  the  tem- 
perature was  104°. 

19th. — At  10  a.  m.  the  pulse  was  120,  and  extremely  feeble, 
scarcely  to  be  felt.  The  patient  seemed  rational.  There  was  no  special 
hardness  of  the  abdomen,  no  great  distension.  Dr.  I^afleur  diagnosed 
perforation  and  the  propriety  of  a  lapanjtomy  was  discussed  and 
neiratived. 


y, 


& 


« > 


,  V 


i 


If  1 


iU 


The  liver  dullness  was  almost  obliterated  in  parasternal  line ' 
there  w..  a  fla  tympan.fc  note.  In  mid-axillary  line  there  was  a 
5th  x.b  m  the  left  antenor  axillary  line.  The  splenic  dullness 
Ttlfatty  "'''  '"  '"'•  '''''  '^'*""'  '"'""^  ^"^'""t^^^'  -^  ^"^" 
Po^^-moV^em,  by  Br.  WeM.-In  peritoneum  25  cc-.  of  offensive 
browmsh-yellow  fluid.  The  lower  coils  of  the  intestines  were  eX 
mosed  ,n  places  and  there  was  exudation  of  fibrin  on  the  surfaee. 
rhe  hver  had  fallen  baek  from  the  abdominal  wall.     The  diaphragm 

on  Z  Tf  \  't  ^""'^^1^""^^^^  *"  tl-  lower  n^argin  of  the  3rd  rib 
on  tlie  left  to  the  upper  margin  of  the  5th. 

In  thorax  there  Avere  no  adhesions. 

Jh  r^  •?''  Tr''/'"'  "  "^'^^''  ""^"""*  "f  blood-stained  serum  in 
each  cavity.  The  heart  weighed  325  gms. ;  the  valves  were  normal, 
the  mu.  alar  substance  flabby  and  pale.  There  was  general  pulmon- 
ale a'dema  m  the  lungs ;  no  foci  of  pneumonia. 

The  spleen  was  large  and  soft;  and  weighed  550  gms 
Ihecapsuleof  the  kidney  was  not  adherent.    The  left  weighed  926 
gms.     rhe  cortex  was  pale-yellow.     The  stria,  were  obscured.     There 

-Both  of  them  siiowed  signs  of  decomposition 

nor^ml/''^''  '''''  '""^^  ^""'^  ^'^''     ^^''  '^''"'^'^  P''^'"*^  '^^^^"'g  ^^'>- 

In  the  intestines  the  first  ulcer  in  the  ileum  was  130  cm.  from 

he  valve.     From  this  point  the  ulcers  were  numerous.     Many  of 

them  were  transverse,  some  presented  the  remains  of  shreddy,  yellow 

6  cm  t  ,       u'^'  fTi'  '  '"'•  ^'""^  '^''  ^"^"•^'  ^^^  -regular  in;hape, 
6  cm.  ,„  lengu,  and  4J  cm.  in  breadth,  with  undermined  edges  and 
a  sloughy,  m<,derately  congested  floor.     Near  the  centre  of  this  were 
two  perforations  about  2  mm.  apart  and  about  2  mm.  each  in  diameter 
In  the  upper  haif  of  the  large  intestine  there  were  a  few  scattered 
elevated    patches  with  yellowish  surfac-es   and   infiltrated    margin. 
M,crosc,>pical  examination  showed  in  the  substance  of  the  kid ' 
ney  epitheluim  of  the  tubules,  granular  and  much  broken  containing 
fatty  globules  of  small  sixe.     There  were  numerous  straight    thick 
non-motor  'jaccilli.  ^    '     ^^' 


5 


parasternal  line.' 
i  7th  interspaces 
line  there  was  a 
led  high  to  the 
splenic  dullness 
uatose  and  died 

cc.  of  offensive 
ines  were  ecchy- 

oii  the  surface. 
The  diaphragm 

of  the  3rd  rib 


lined  serum  in 
is  were  normal, 
eneral  i^ulmon- 

ns. 

'{t  weighed  226 
seured.  There 
ame  condition. 

■d  nothing  ab- 

130  cm.  from 
•us.     Many  of 
u-eddy,  yellow 
^ular  in  shape, 
ned  edges  and 
e  of  this  were 
h  in  diameter, 
few  scattered 
ited    margins. 
s  of  tlie  kid- 
:en  containing 
raight,  thick, 


The  heart  muscle  showed  fine  granules  and  a  few  oil  globules. 

This  case  offered  much  difficulty  in  the  diagnosis.  We  thought  at 
first  it  might  be  malarial  remittent  fever  but  as  the  examination  of 
the  blood  proved  negative,  this  was  excluded.  The  persistence  of 
the  fever  at  a  high  level  and  the  dicrotic  character  of  the  pulse  fa- 
vored typhoid  fever.  The  latter  symptom  was  regarded  as  very  sug- 
gestive, but  it  is  curious  that  several  writers  have  noted,  particularly 
in  these  forms  of  renal  typhoid,  the  absence  of  dicrotisni.  The  oc- 
currence of  profuse  hemoglobinuria,  with  his  severe  initial  chill  again 
suggested  malaria,  l)ut  we  relied  upon  the  negative  character  of  blood 
examination  to  exclude  this.  There  were  practically  no  abdominal 
symptoms  other  tlian  slight  pain.  It  was  not  until  tiie  seventh  day 
in  the  hospital  that  he  had  diarrhoea  and  this  followed  the  chill,  asso- 
ciated with  the  perfi)ration.  The  I'igor,  the  colkipse  tempeniture,  the 
pain  in  abdomen  with  slight  swelling  and  more  particularly  the 
almost  complete  obliteration  of  the  liver  dullness  in  the  mammary 
line,  led  Dr.  Lafleur  to  the  diagnosis  of  perforative  peritonitis. 

Case  II. —  Gradual  onset,  with  femr  and  eouyh  ;  no  rigor.  Besfless 
delirium,  diarrhau ;  well  marked  rash.  Much  albumen  and 
many  tube  casts  in  urine.  Remarkably  low  temperatures.  Acute 
otitis  media.  Death  about  22nd  day.  E.densive  ulceration  in 
ileum.     Acute  nephritis. 

Josie  H.,  aged  25,  was  admitted  to  the  Philadelphia  Hospital  on 
October  9th  in  a  condition  of  delirium.  From  her  friends  the  fol- 
lowing history  was  obtained. 

She  had  enjoyed  good  health  witli  the  exception  of  an  illness  of 
three  months  duration,  eight  years  ago.  which  had  followed  the  birth 
of  a  child. 

She  had  been  complaining  for  a  few  days  of  headache  and  of  a 
feeling  of  fatigue  and  loss  of  appetite.  She  had  a  slight  cough,  but 
no  expectoration  ;  was  feverish  at  times  in  the  evening  and  her  sleep 
was  disturbed.  She  kept  at  work  until  Saturday  the  oth  and  on 
Sunday  the  6th  took  to  her  bed,  the  fever  becoming  more  marked. 

On  admission,  the  temperature  was  104.2°,  pulse  123,  not  dicrotic, 
respirations  22.  The  patient  answered  questions,  but  rambled  at 
times.      The  tongue  was  dry  and  tremulous ;  examination  of  the 


li 


•H 


i   . 

\ 

1 

i 
1 

m 

i'i 

i 

i 

1            < 

>  I 


m- 


■I  If 


:  !  ! 

1    ■; 

i 

1.     , 

!  4 
if 

J 

1; 

ot  bod.      I  he  pulse  raneed  fV„m  100  tn  ^'i(^    '    i'      .,      ^ 

of  the  12th  rose  to  160      Til  '       ^'  """  ^'''^  ^''"'^'"g 

10th  and  1  If h    n  I  ""'  '"^'""t"""' ^««  of  „ri„e  on  the 

ha        ,  K.  doses,  and  a  digitalis  ponltieo  on  the  abdomen.  '  On  the 

dinun,  was  n.a.-ked  '  "'  "'^"  '^^^"^^  -osultus  ten- 

On  the  13tl,  she  refused  to  take  nonrishment.     The  tenn.erature 
at  -3  a.  m.  was  100.8°-  at  12  m     ini  ro     ,   ,  ronij)eiature 

mv^^.4  .      IJie  temperature  remained  low  all  niirht  nt  m  ,  v 

registered  97.4°;  at  4  a.  m.,  97.2°;  at  7  a   m  iH        TI       ^'i  ""•  '' 
small,  llo  to   100       ^iw.  f     i  ,  "     ^^^^^  P"Jse  was 

9^0  /  *""'''  "'^"i-'slii^ent  better  and  there  werP 

250  cc.  of  urine  passed  on  the  13th 

^_  Tl|o  following  notes  were  made  of  her  condition  at  the  mid-day 

iica\\   sediment  of  mucus;  snec  fie  p-rivlfv  moo  ^- 

.it,,  „i.Hc  acid,  a  co„i„..  p.«i  i.a^^f  XL  f I  . S';",  rl' 

WP,-P  t-V,  „  (•  J  •''  '™"'  '"  <«"«  'l'»t  at.  first  el.ev 

^^\!^  I«"<i„-c«s  of  srfi,„ent.     N„„:o,-„„s  speci„,e„,  wZ 

:pr:v:^;rL~-:srir:;;:r::;^ 


the  bladder  tlier 


e  were 


rflles  ill  tho  upper 
Jver  ranged  from 
)ols  on  the  10th, 
were  water}'  and 
rying  to  get  out 
I  on  the  evening 

of  urine  on  the 
>n.  Tlie  amount 
*'.  On  the  12th 
were  withdrawn 
tube  casts.     On 

small  that  Dr. 
1  of  digitalis  in 
lonien.  On  the 
)igastrio  regions. 
g  suDsiiltus  ten- 

iio  temperature 
L01°;at6.30p. 
at  10  p.  m.  it 
TJio  pulse  was 
md  there  were 

it  the  mid-day 

as  a  distressed, 
S' ;  pulse  rapid 
vertical  splenic 
with  deposit  of 
reaction  acid; 
third  by  bulk 
)us  large  and 
t  at  first  they 
lecimens  were 
le  with  a  tew 
e  coarse  gran- 
and,  in  a  few, 
er  there  Mere 


numerous  bacilli,  some  of  which  seemed  to  be  in  the  tube  casts.    Here 
and  there  red  blood  corpuscles  were  seen  but  they  were  not  numerous." 

On  the  14th  the  teini)erature,  wiiicli  had  been  subnormal  at  7  a.  m. 
roso  by  noon  to  100.4°,  and  for  the  remainder  t)f  the  day  it  kept  be- 
tween 104°  and  105.o°.  She  passed  440  cc.  of  urine  in  the  twenty- 
four  hours  and  slept  better.     She  also  took  more  food. 

On  the  loth  the  tem{)erature  at  8  a.  m.  was  97.3°  ;  at  2  p.  m.  it 
rose  to  101.4°,  juid  the  pulse  ranged  from  120  to  140.  There  was 
a  discharge  of  blood-stained  iluid  from  the  right  ear ;  nothing  to  be 
seen  in  the  meatus  and  no  tenderness  over  the  mastoid  process.  In 
the  evening  the  temperature  again  sank  l)el()w  normal,  and  at  10 
p.  m.,  1  a.  m.  and  4  a.  m.  it  stood  at  97.8°. 

On  the  IGth  the  temperature  was  99.2°  in  the  morning.  She  had 
had  a  restless  night,  but  looked  better  in  tlu;  morning.  She  had 
passed  urine  involuntarily  and  the  (piantity  for  the  twenty-four  hours 
was  therefore  doubtful.  The  discharge  from  the  right  ear  continued 
and  there  was  n'o  special  tenderness  on  either  side  of  the  head. 

The  anomalous  temperature  curve  and  the  discharoe  from  the  rio-ht 
ear  suggested  a  doubt  as  to  the  true  nature  of  the  case.  Puncture  of 
spleen  was  made  with  a  fine  hypodermic  needle  and  cultures  prepared 
from  the  fluid.     Aft(>r  midnight  the  temperature  again  sank. 

On  the  morning  of  the  17th  the  temperature  was  97.8°,  remained 
about  99°  all  day,  but  at  8  p.  ra.  sank  to  97.4°.  The  pulse  was  120, 
very  feeble  ;  passed  a  very  (piiet  day  and  seemed  to  recognize  her 
friends. 

On  the  18th  the  temperature  at  1  a.  m.  was  97°  and  by  8  a.  m. 
rose  to  98.8°.  The  urine  presented  the  same  features  as  before,  but 
the  granular  casts  were  less  numerous  ;  the  amount  of  albumen  was 
large,  and  bacilli  were  still  seen  in  the  urine  withdrawn  with  careful 
antiseptic  i>recautions.  The  continued  hw  temperature  necessitattHi 
the  constant  application  of  hot  cans.  The  bowels  had  not  moved 
for  several  days.     The  delirium  persisted. 

On  the  19th,  the  temperature  at  o  a.  m.,  was  96.4°  ;  at  8  a.  m. 
96.8°;  pulse  very  feeble  140.  She  was  given  an  injection  which 
brought  away  a  partly  formed  yellowish  stool.  At  2  p.  m.  the  ther- 
mometer in  the  axilla  could  not  be  made  to  register  more  than  95°. 
The  patient  seemed  ^'ery  dull,  heavy  and  lethargic.  At  3  p.  m.  the 
temperature  rose  to  96.4°  and  by  5  p.  m.  it  was  98.4°.     She  had 


i  J 


/.<■ 


i  ' 


8 

hicoouffh  through  the  day  and  more  rapid  respiration     Tl.n  . 

tare  at  8  n  m   wm  07°     „.  in  1       resjuiation.     The  tempera- 

'i  '?n       .1  '  "*  ^^^  ''•  '"^  '^^•4°  and  death  took  i,laee  it 

o.dOon  the  morn  iKrnf  flir.  9nfi.     •   ix        i  piace  at 

wdl-„,a,l,.,  „-..||-„ .i,|,e,l  y„„n..  w„ma„-  (I,.  ^      ^ 

8i.l<.r„l,:,.  ,li»,.|,a,.,.,.  ,■,,„„  ,|,e,.i«l^  elr      '  "  '"''"'  '^°"- 

Al„l„„„.„.     Tl„.  |H.rit„no>,m  m„  s,„,Krt|, ,  ,|„.  |.,„,,,.  ,„:, ,  ,  f  „ 

Stomach  and  duodenum  showed  no  speeial  ehan^m^      TI,.  •  • 

The  mesenteric,  ghtnd.s  Mere  greatly  enlarged  and  deeply  congested 
One  presented  a  soft  eheesv  r-enti-p      Ti,^  i-  ,    ^"-^  '""fe's^PO- 

full  of  uo,Ki,  .he  sui^tar,:.:;;,;:,,,^""  ■■"'■ "-"  '"'■«^'  '"^  --*  . 

giammo.,  the  capsules  were  thin  an.i  ,-,.a.lil,v  detaehed ;  the  SMvfaoe 


9 


The  tempera- 

i  took  i)lac'c  at 

kiiiffto  her  bed. 

was   that  of  a 

^vas  pale;  con- 

cr  coils  of  the 
s  swollen, 
ht  pleura ;  the 
ic  heart  was  of 
i?lit  chambers; 
a  little  pale. 
■!  ha?morrhage, 
ally  abundant 

itio  congestion 

ned ;  no  trace 

The  jejunum 
'Gued,  and  at 
was  swollen 
dozen  small 
ir  tissue,  and 
er  foot  of  the 
or  four  large 
!  seen.     One 
•e  and  there 
leers.      The 
ntestine  was 
!iT?morrhagie 
•e  of  even  a 

►^  congested, 
the  vessels 

about   400 
the  surfltce 


was  pale  and  mottled  by  the  presence  of  ninuerous  stellated  veins. 
On  section,  the  sul)staiice  was  miiist  and  from  the  larger  veins  blood 
flowed  freely.  There'  was  marked  contrast  between  the  cortex  and 
pyramids,  the  former  being  greyish-white  and  uniform.  The  tubuli 
Bellini  appeared  swollen  and  presented  only  liere  and  tluMe  a  fnll 
vessel  or  e(ingest<d  Malpigliian  tuft.  Xo  loealized  opaijuc;  areas. 
The  j)yramids  were  congested  anil  the  vessels  and  veins  at  the 
bases  were  distende<l  with  blood,  lli.-tologiially  the  ehangcs  found 
may  be  thus  summarized:  (1)  Glomerulo-nephritis  involving  both 
the  vascular  and  capsular  epithelial  lining.  The  tuft  was  often 
partially  com])ressed  by  graiuilar  d.'bris  and  rounded  cells  which 
stained  badly.  (2)  Dilatation  of  the  eonvoluted  tubes  with  extensive 
ne(Tosis  of  the  epithelium,  vvhieli,  as  granular  matter,  filled  the  lu- 
men. In  places  large  tubes  were  distended  with  the  pale  round  cells 
noticed  in  the  capsules.  Q))  In  spots  atroj)hy  of  the  tufts  with 
fibroid  change  about  them — proi)al)lyan  okU-r  process. 

Uterus  normal.     liladder  tightly  contracted  ;  mucosa  hypera}mic. 

There  was  reddish,  grey  exudation  in  the  right  tympanum  ;  the 
drum  was  perforated.  The  iutkunation  had  not  extended  to  the 
mastoid  cells. 

Tile  brain  showed  congestion  of  the  cortical  veins;  substance  nor- 
mal ;  no  extension  (»f  inllammatiou  from  tlu;  ear. 

This  case  presents  an  entirely  different  clinical  picture  from  the  first. 
The  slow  onset,  fever,  dry  tongue,  bronchitic  n'des,  slight  diarrhoea,  left 
very  little  doubt  at  the  time  of  her  admission  that  the  case  was  one 
of  typhoid  fever.  The  extraordinary  ranges  in  the  temj)erature,  with 
the  occurrence  of  an  otitis  media  and  the  renal  symptoms,  shook  this 
ojjinion  somewhat  for  a  few  days,  and  it  was  then  that  Dr.  Shake- 
speare was  asked  to  make  cultures  from  a  blood  drop  from  the  spleen, 
in  which  were  characteristic  typhoid  bacilli.  By  far  the  most  interesting 
feature  in  this  case,  possibly  associated  with  the  nephritis,  was  the  ex- 
tremely irregular  temperature  ;  thus,  on  the  l;3th,  the  fourth  day  of 
her  admission,  after  the  temperature  had  been  ranging  from  102°  to 
104°,  it  fell  at  G.30  p.  m.  to  97.4°,  and  remained  about  this  point  all 
night,  registering  at  7  a.  m.  96.4°.  I  was  afraid,  at  the  mid-day 
visit,  that  hemorrhage  or  perforation  had  occurred.  She  rallied, 
however,  and  by  the  evening  the  fever  was  higher  than  it  had  reached 
previously,  105.5°.     On  the  mornings  of  the  loth,  16th,  17th  and 


■■•  i 


^U 


fh 


10 

18th   the  teinpomture  ysas  uLso  suh„„nn.al.     It  nsuullv  rose  in  the 
eve.H„,  to  I0;j°  and  104°.     Throughout  the  IDth,  the  th.n  u  1 
only  once  registered  97°.  'Juomncr 

These  eases,  both  unhappily  fiUal.  ilh.s.rute  the  main  features  of 
th.s  senous  eoniph.alion.      I>raetieali v  we  have  to  deal  with  an  acute 
m  most  instances,  a  he.norrluigic  u.^phritis.     Xaturally  i,  adds  n.uch' 

l^r7  ''  'Tr'  ^"'  ^'^"  '"••'^"•-^  '«  always  rendered  u.ore 
dubious  Uagner,'  however,  has  had  tive  eases  of  recovery  in  sue- 
c-<..s,on,  hut  the  h„h  nu.rtality  nu-ntioned  by  Amat-10  deaths  i'. 
iz  cases— IS  the  more  common  expr  rienf.. 

A  discussion  of  the  r.-lation  of  this  forni  of  nephritis  to  the  tvphoid 

rr  u7  '"'.'"T^  '""^^'>'  ^'y  *''^'  '^"^"■"'  ^'^'  ^y  ^'---  l>t"-. Lines 
or  the  result  of  a  mixed  infection-would  be  beside  my  present  pu 

po^j  ^v^nch  ,s  soldy  clinical  ;  nor  <lo  I  think  the  ma^Hals  are'^  t 

ava  lable  for  a  solution  of  this  problem,  one  of  the  most  complex 

in  the  pathology  of  the  i.ifectious  discuses.  ^ 


•  DeutBches  Arehiv  fur  Kli...  Med,  Uds.  xxv  and  xxxvii. 


C  i/  III 


ally  rose  in  the 
'ui  thonuoiuetor 

aiii  features  of 
1  with  Jill  acute, 
y  i(  ailds  much 
rendered  more 
icovery  in  sue- 
—10  deatii.s  in 

to  the  typhoid 
heir  ptomuines 
^  present  pur- 
erials  are  yet 
most  complex 


I  From  Th,  John,  Hopkins  Ho,pi,a1  Bulletin.  Vo,.  ,,  No.  6,  M.j, ,««,,] 


ON  THK  AMCEBA  COLI  IX  DYSEN !  HRY  AND  IN 
DYSENTERIC  LIVER  ABSCESS. 


ordinary  „„„.berH  an.i  presented  all  the  -haracters  of  ama,b«     Th"  m<  vo 
^ents  were  extr.„,ely  active  and  the  elaborar.  description  which  he"  es" 
migh   have  been  wntten  from  a  .tudy  of  the  specimens  in  which  we  "hive 
here  been  interested.     He  iiyeoted  the  stools  containing  amX  Tnto  Z 
rectum  of  three  dogs,  in  one  of  which,  ,.t  the  end  of  dgh  ee„  dai    he 

basis  of  a  small  ulcer  which  had  formed 

Kartnli8,3  stimulated  by  the  observations  of  Koch,  who  found,  during  his 
cholera  investigations  in  Egypt  in  1883,  amceba.  in  sections  of  i\.  in  e"fine 
of  persons  dead  o.  dysentery,  examined  150  cases  in  a  period  of  two  yZ 
and  in  every  one  found  these  organisms  in  the  stook     In  twelve  pos 
mortems  the  amceba-  were  present  in  the  ulcers  in  every  case 

cases  '  ""■'  '"""*  "  '"  '''■•^"  "'  ''"  ^''■•'''^ '"  *-'»"  -»'^  --^  chronic 

orc^.'  *;"%7*^"^«d  his  studies  on  this  question  to  the  liver  abscesses,  which 
occur  so  often  m  connection  with  dysentery.^  In  .„  examination  of  twemv 
hver  absce^es  he  found  the  amceb«  in  actions  of  the  walls  in  everv  c^^^ 
In  one  instance  he  found  a  living  amceba  in  the  pus  of  the  ablcelTx 
amined  Iresh  af.er  death.  They  presented  the  same  characLrs  S  tl^" 
para  ites  which  he  had  found  in  the  large  intestines.  In  Virchow's  Archiv^ 
Bd  108.  he  gives  a  fuller  account  of  his  observations.  He  has  met  with 
he  parasites  in  more  than  500  cases  of  dysentery,  and  in  all  the  cases  of 
hver  abscess  due  to  this  disease  which  he  has  examined.  In  thirteen  of 
twenty-two  instances  of  these  abscesses  cultures  were  made,  eight  of  which 

'  yuoied  by  Leukart,  Paraslten,  zwte  Auflage,  Lief,  I,  p  23.3 
» Virebow's  Archiv,  Bd.  65.  > »        • 

s  Virchow's  Archiv,  Bd.  105. 
*  Centralblatt  fiir  Bakteriologie  und  Parasitenkunde,  1887,  p.  74,1 


^H 

; 

f,^' 

^^H 

( 

^H 

■    ) 

^H 

i      V 

" 

^^^^V 

1                  <^-< 

^^^^^^^H 

^^^B 

.>  I 

^^^^^^^Ki- 

1' 

^^^^^^^^■i     { 

J:.,}:: 

^^^H! 

1     '          f , 

^B' '  ' 

"            , 

^^^B' 

I'll-'     ' 

^B  : 

^^^H'  j 

,    !'■    . 

f .  1 

1 

H ' 

I    ;.!/:  '  k 

' 

:■      \  r  '        i 

i.         !     ..                r 

W 

B  J  ' 

^H||  m 

1 

^H ' 

^^^^E 

B  it-'  1' 

■t  i 

.!'     n   -: 

HII 

«i "' 

b|^^^^ii| 

III 

were  .u^ative ;  in  tl.roe  there  were  s,aphyl.>co<^ci,  in  one  the  A.«./».  /W./u. 
and  in  one  the  pvoteu.  vulgari,.  He  hoUln  that  the  ama-lm..  >vh..i.  ex,.t  m 
all  the  !ayer«..rthe  inteHtines  in  ay«ent,-rie  nUeration,  paH.  with  the  n.ieru- 
cirKaniMMH  and  detritnH  through  the  portal  veins  to  the  l.ver.  1  he  micro- 
cocci excite  the  «uppnration,  but  only  in  consequen-e  of  the  leH.ons  ...  n  el 
hv  the  amoeba..  The  pns  seems  to  die  rapidly  in  the  absceMoH,  bnt  the 
aLb,e  remuine.1  alive  for  a  n.u.h  longer  period  often  over  two  .nonthH^ 
HiHtoloKically,  KartuliH  deHcriben  three  /.onen  .n  theab«ce.H  NvaU.-hrst,  e 
detritus  zone,  containing  fibrous  granulations  and  amroii  second  the 
cell  .one,  consisting  of  youn«  cells  which  stain  deeply  and  between  wh.ch 
can  be  seen  p<.rtions  of  liver  tissue,  liver  cells  and  capillunrs,  and  tlur.l, 
the  limitation  .one.  separating  the  disease  fron.  the  >ntact  hver  tissues. 
His  n.ost  recent  communication  i«  in  the  C'entralblatt  fur  f 'f  «■'  S' 
No.  •-',  1890,  in  which  he  reports  two  Cases  of  dysentei  y  whveh  had  origin- 
ated in  Athens,  in  both  of  which  a.n.«ba.  were  present  in  the  stools, 
similnr  in  character  to  those  met  with  in  the  Egyptian  dvsentery. 

Massiutin '  has  stu.lied  this  question  under  Losch's  supervision.  He  has 
found  the  parasites  in  live  [.atients-one,  a  ease  of  chronic  dysentery  of 
seven  vears  standing ;  the  second,  a  man  with  chronic  intestinal  catar 
a  third,  a  case  of  typhoid  fever  with  late  diarrhea  and  mudi  mucus  in  the 
stools  ;  the  fourth  and  fifth  were  cases  of  diarrhea  with  fluid  '""^f  *,toob. 
The  ama-bic  presented  active  movements  and  seemed  o  have  the  same 
characters  as  those  described  by  Kartulis.  He  <ioubts  their  connection  with 
the  intestinal  condition.  He  thinks  that  they  gain  access  to  the  ii.testu.e 
through  the  water  and  find  in  the  mucus  of  the  colon  situations  suitable  for 

''"BLfm'l^inen^  comments  as  follows  upon  the  view  of  Kartulis  that  the 
amell  constitute  the  exciting  agents  in  th-^  ■':sease.  "  We  will  not  contra- 
dict this  view,  although,  as  many  old  anu  <.  .t  observations  «1>-V  -  > 
siuular  anueboid  forms  occur  in  other  i  .-  nal  afiections  -'>d  <^;  "  " 
normal  f.eces.  We  regard  it.  however,  as  uu.kely  that  Uie  -"^^a  .  ild 
induce  all  of  the  conditions  in  the  dysenteric  processes.  Dysentery  (onsists 
anatomicallv  in  a  combination  of  diphtheritic  and  purulent  inflammation, 
whic!^.  i„d„ees  rapid  and  deep  ulceration  of  the  affected  part.  We  have  no 
Tnalogy  to  show'that  ameboid  parasites  can  i-'>-  "'-''"-'  ""^^^^^^ 
rather  believe  that  the  ,.yogenic  micro-organisms,  well  known  as  exc  er 
ulcerative  processes,  are  concerned  with  the  am^lue  in  the  causation  of 

tropical  dvsentery."  u-     ,      i   i,..,i 

This  practically  embraces  the  entire  literature  of  the  subject.  I  had, 
after  the  publication  of  Kartulis'  paper,  made  several  examinations  in 
Philadelphia  with  negative  results.  During  a  visit  to  the  Hospital  Dr. 
Lut.e,'  last  October,  stimulated  our  interest  in  the  matter  -  h-'a  d 
that  he  had  frequently  met  with  the  parasites  in  tropical  ,lysenlery.     We 


5  Abstract  in  Centralblatt  fur  Bakteriologle  Bd.  «,  p.  4ol. 


cilhiK  f<ftiiiu.i 
licit  exii<t  in 
,1j  tlie  micro- 
Tiie  inioro- 
ions  imluced 
MoH,  but  tlie 
two  months. 

wt'oiui,  the 
•tween  whicii 
8,  and  third, 
livor  tisHUes. 
{akteriologie, 

I  liiid  origin- 
n  tl\e  stools, 
tcry, 

lion.  He  has 
dysentery  of 
inal  catarrh  ; 
iniious  in  tlie 
mucoid  stools, 
ave  the  same 
innection  witli 
)  the  intestine 
ms  suitable  for 

tulis  that  the 
,ill  not  fontra- 
ins  show,  very 
i  and  even  in 

amoeba^  could 
entery  consists 

inflammation, 

We  have  no 

ration  and   we 

II  ah  exciters  of 
[6  causation  of 

nbject.  1  had, 
saminations  in 
e  Hospital,  Dr. 
;r  as  he  stated 
lysentery.     We 


Samlwicii  l-ilanda. 


3 

lervatlo  n  '■;"""'""•     ''"■""'■^'  '"'^"-^-  »  '•»-  »'-  '-  "  "nde 

0  ervafon  .n  whuh  the  a,u...l,...  have  been  .oun.l,  not  only  in  the  .too I, 
bu  n  e„orn.ous  numbers  i„  ,1..  pus  of  abscesses  o  the  liver  'Z  M 
of  the  ease  are  as  follows:  '"'" 

nr.  a,  age  29,  resident  i,   (•«„„„.,   ^;,,  nearly  six  years  where  he  Ir.d 

M:::^:ir"r ^""'^  '■ " ^"'"^^ "'^*^' -- -r;: m- ;  J : 

short  tune  at  his  home  ,n  BulM-nore,  w  ..t  to  (Jermanv.     He  ha.l  intervals 

he  1  J  had  "  ..•  '  "^T"  '■?'""""  ^^'^^  ^'*"-y  «"••<». -nsideriuK  that 
nt  I  ul  had  severe  .iysentery  and  an  irregular  fever  for  more  than  two 
months.     The  liver  was  slightly  enlarKcd  anteriorlv  but  no  Ic  d   ^  se,, 

T::J:Tt':'r  ^"""- v° '-  - '-''  '''^''-^'^  -'-«'-  ^^ "« - 

pra.  ticallv  the  M.me.     Ihe  temperature  rose  eaeh  dav  to  al,out  103°    There 
were  no  pos.tlve  chills  but  occasionally  towar.l  the  nHcrnoon     e   ,  mpl     u" 
o    sensat.ons  „f  cold      The  diarrhea  lessened  and  his  uppe  ttc    ^p  o    d 
b      n,  spue  o,  tins  he  had  lost  flesh  and  strength.     An  eriorlv,  tl  eTv"; 

b  eadth  above  the  norn,al  li.nit.     There  was  distin,..  sensitiveness  on  deep 

ir,  gKiu.i,  pan,  whenever  he  turned  upon  his  left  si.le.     The  sus„icion 
entertained  atfirstti.at  he  had  ab.cssof  the  liver  w,.  gradualy  co'e 
and  o..  March  22n.l  D.-.  Ti.lany  .spirted,  and  then  Lised  UtZ^ 

h  d lul  re^d-TT''^'"'"'  '."  ^'"''"'  '"  ^'-"''^  ■^'•«'^">'  Wl-^tained,  bu.  it 
had  not  the  redd.sh-brow.  and  anchovy-sauce-likc  appearance  presented  by 
the  pus  in  many  cases  of  he|>atic  abscesses.  ^ 

1  made  an  exan.ination  of  the  pus  at  the  Uiological  Laboratorv  within 
three-,uar,ers  of  an  hour  of  its  withdrawal  and  found  in  t  i'n  la  e 
numbers,  the  anm-b.  which   Kartulis  had  described.    The    n  le  h    u£ 

aken  at  once  to  the  Pathologic  laboratory  where  Prof  V  ^  1  l" 
Counctlman  con.n.n.ed  the  okserva.ion.  On  each  succeeding  ay  the 
tune  of  dressing,  pus  was  removed  from  the  drainage  tube  l,efore  iVril  on 
was  begun.  n  the  first  two  days  the  amceb.  were  quite  numerou  a  iS 
;:•  ,t;\_  -^'-'"-«  following  days  they  weresti?i  found,  but  .no;;! 
tOTMs  were  n„t  .o  common,  p.ubaldy  owing  to  the  fact  that  stron-^er  solu- 
tions of  bichloride  were  used  for  irrigation.  Subsequentiv  thev  ..C  ve  v 
numerous,  and  we  found  them  each  day.  in  the  pus  as  it  eanie  from  he  i  rZ 
age  tube,  until  his  death  on  April  5th. 


i[ 


! 


ill-  I 


iffipH^ 


After  the  operation  the  dysenteric  sympton^B  did  not  abate  ,n  the  shght- 
e.tThe  continued  to  have  from  eight  to  -^-"  -;;™^;,t  L  ^^^^^^ 
varied  a  good  deal  in  f^;^r:ZZ::^lTt:::^er.  .ade 
and  there  with  pus  and  P'-^*^"^'"^/  '''^;''l;  „„  several  occasions,  there 
np  of  a  greenish    pu  tae.ous  --^-^^^^-^^^ifj^  usually  slight  in 

were  '-g-"«^"j-,^«;^^;  ^  J,f  fi,"  ^    ,,ownish  liquid  evacuation,  in 
amount.     Occasionally  theie  wa^  .i  i<itf,  l„jj„j  :„  blood-stained 

them. 

Description  of  the  amcebie.  ,  *«  90  u    which  appears 

(a)  From  the  liver.    The  si.e  ranged  from  ^^^  ^^1^  ^e't  the 

to  be  somewhat  greater  than  ^-^]^^'^^l^^^ .^.o^on  they 

outline  was  usually  circnhn-,  ---"fj^^^^^trg.iU   contour  of  moving 

as  a  rule,  very  distinct  and  in  ^^^^^J^^^'^LJ^  a  form 
the  interior  was  surrounded  by  it  as  a  ^'^tmct  i.m 

was  seen  in  which  this  portion  was  much  ^^^   '^^  "^   ^^^^^  ^vithin  the 
part  of  the  organism  seemed  composed  of  gnvmda,  -^^^-^^  ^^^^^.,^^^  ,,, 

Ldosarc,  the  vacuoles  «-^;^';;t:  ^r  :   f    se^^       f^  -'-  ^lear 

interior  substance  appeared  to  be  made  up  ot  a  se 

pulsations  but  the  larger  vac-oles  underwent  at  t-e-';-f^.^\,„i,  ^,  .^. 
nucleus  was  plain  enough  in  some  ^--^V^^S  o  rolded  in  outline  and 
^^:;^.  rr  N^  d£;:::::^el™  se^,  U^ugh  there 
V^  :Sme.^  ^oarser  granules  ^^^^^^l^^^^:^,.  .„  distin- 
When  once  recognized,  there  ^-//'/^^^^''^hel  elements,  not  only 
guishin.^  these  bodies,  even  '^h^"  ^^      t  Ze  r!nce  of  the  protoplasm. 

Ml  the  movements.     Ihough somen  ,  ^^^^^  ^ 


5 


at  imes  more  active  apparently  than  at  others,  and  the  movements  went  on 
at  the  average  laboratory  temperature,  but  seemed  increased  by  heat.  Thev 
continued  active  for  hours  at  a  time.  Twice  the  movements  were  observed 
to  continue  in  the  same  organism  for  more  than  ten  hour« 

6)  The  amoebre  from  the  stools.  During  the  month  or  ..ore  in  which  the 
patient  was  under  observation,  the  diarrhoea  was  a  marked  feature.  Tenes- 
mus was  rarely  present  and  the  frequency  of  the  stools  was  from  four  to 
twelve  in  the  twenty-four  hours.  The  character  varied  very  much.  Some- 
times he  had  a  large  brownish  fluid  evacuation  with  little  or  no  mucus; 
more  frequently  three  or  four  ounces  were  passed  at  a  time  and  scattered 
through  the  brownish  liquid  mucus,  blood  and  small  .diitish  sloughs  could 
De  seen.  On  several  occasions,  the  stools  seemed  to  be  made  up  of  a  gela- 
tinous mucus,  streaked  with  blood,  and  twice  large  grayish  sloughs  were 
tound.  Experience  showed  that  the  amoebaj  were  rarely  found  in  the 
brownish  liquid  stools.  In  the  mucus  they  were  more  fiequent,  but  they 
were  met  with  in  large  numbers  only  in  the  small  gravish  fragments,  por- 
tions, no  doubt,  of  sloughs  whic'-i  were  present  in  variable  numbers  in  almost 
every  mucoid  stool. 

The  general  character  of  the  amoebae  corresponded  in  every  particular  with 
hose  tound  in  the  liver.  A  greater  variation,  perhaps,  in  size  was  noticed, 
but  in  the  appearance  of  the  protoplasm,  the  character  of  the  movements, 
and  the  arrangement  of  the  vacuoles,  no  essential  difference  was  noted. 

It  18  impossible  to  speak  as  yet  with  any  certainty  as  to  the  relation  of 
these  organisms  to  the  dis-ase.  The  subject  is  deserving  of  extended  study, 
and  a  point  of  special  interest  will  be  the  determination  of  their  presence 
in  the  endemic  dysentery  of  this  country. 


■k 


1 
■I'll' 


ilMM* 


C  /x 


[Reprinted  fromTm.;  Medical  News,  December 


20,  1890.] 


ON    THE  FORM   OF   CONVULSIVE   TIC   ASSO 
CIATED    WITH   CO  R  PR  0  LA  L  1 1  ETC 

Johns  Hopkms  Hospital.  Baltimore,  Octohc-  ,,,  ,Sgo. 
nv  WILLI  A. \r   OSLFR,  M.D. 

rHOHHSSOK  OP  T„.   P.u.cP.ns  ANU   PHACT.CK   C    M.U.CNB 
JOH.Vi    HOPKINS    UNIVKKSITV.  ' 


more  coi recti)     symptom-group-met    with   d  ieHy  in 
children,  to  wh.ch  attention  has  been  called  o    hte  b 
French    wr.ters,  which   is   characterised    by   Le.ula' 
spasmodic  movements,  the  utterance  of  invoh.ntarv  ex'* 

t^'u^:^^'''-''-'  --'^^  defect?:"  vS:i  s- 

JnH  t'  .  1      u         ^'y  '^«'""''^n  aftection  in  this  country 
and  I  take  this  opportunity  to  bring  to  your  notice  a  cSe 

l^he  cases  hve  usually  been  described  as  chorea  or 

very  closely  by  the  irregular  movements-    certain   in 
stances  also  have  been  reported  as  hysteria. 

name.?,/,/    ?        •  ^^^^  ^^'^^'^  '«  "^'^  ^^ection  the 
name  ;«<^W^,  ,^,,  /,,,  ,,,„„,^,,^,      j  unfortunatelv 

or  here  and  in  England  we  use  the  term  ....S    Z- 

to  characterize   a   totally  different  affection    involving 

usually  the  facial  muscles  and  of  either  central  o   "r  2 

eral  ongin,  but   not   necessarily  coming  on   in    chiM 

hood  and  not  characterized  b/the  other  fev  les  p  e" 

sen  ed   by   the    disease  of   which   we   are   a    ^  es^^.^; 

speaking;  and  thus  it  happens  that  if  we  turn  to  the 


time  past  he  has  not  felt  as  well  as  usual.  On  November  1st  while  at  his 
supper,  in  a  restaurant,  he  found  that  he  could  not  read  the  daily  paper 
He  was  sure  that  this  camo  on  quickly,  and  had  been  his  chief  annoy- 
ance, as  he  was  an  ardent  politician.     He  had  no  definite  headache,  but 


IM[  :^       I        y ,  i] 


2 


OSLER, 


iH 


c<^. 


recent  editions  of  French  books  we  find  under  tic  con- 
"nthif-A  disease  very  different  from  that  described  by  the 
same  name  in  EngHsh  and  American  works. 

The  history  of  our  patient  is  briefly  as  follows : 

Mary ,  aged  thirteen  years,  applied  at  the  out- 
patient departmentj,July  loth,  and  was  under  observa-  J  ■  /-/  /-t 
tion  there  until  September  i6th,  when  she  was  admitted 
to  ward  G.  Her  mother  brought  her  to  the  hospital  on 
account  of  irregular  involuntary  movements  and  curious 
barking-sounds. 

Her  family  history  is  good.  Her  mother  is  a  bright, 
intelligent  woman,  a  German  by  birth,  and  has  had  ten 
children,  none  of  whom  have  been  affected  as  is  this 
girl— the  third  child.  There  is  no  tendency  to  mental 
disease  in  the  family.  The  birth  of  the  child  was  normal 
and  there  is  no  history  of  convulsions  in  infancy.  She 
has  had  scarlet  fever,  but  has  not  had  rheumatism. 

Since  her  fifth  year  she  has  been  subject  to  invol- 
untary jerking  movements  of  the  arms  an  head,  which 
vary  very  much  in  intensity,  sometimes  bet  ,  sometimes 
worse,  and  they  have  usually  been  called  '  j  the  doctors 
chorea.  They  have  not  interfered  with  her  development 
or  her  education.  She  has  not  yet  menstruated.  For  the 
past  year  she  has  been  making  curious  sounds ;  hegin- 
ning  by  saying  "  hah  "  very  frequently.  Sometimes  she 
would  bark  like  a  dog.  She  would  also  call  out  the 
names  of  people,  and  if  she  heard  a  new  name  she 
would  be  apt  to  repeat  it. 

Her  condition  on  admission  was  as  follows  :  A  bright, 
intelligent  child  ;  well  educated,  writes  nicely,  takes  an 
interest  in  her  books  and  has  evidently  been  ambitious 
at  school.  She  is  nervous,  the  right  arm  occasionally 
twitches  and  the  head  jerks.  There  are  no  grimaces, 
but  on  several  occasions  she  seemed  to  mimic  move- 
ments of  the  face.  Every  now  and  then  she  ral'":  out 
"hah,"  "Bridget,"  or  "stools,"  or  says  in  s  -  dear 
tones,  "bow,  wow."     There  are  no  disturb:  .'CCj  o.  f!n- 


■u 


\ 


1 


nder  tic  con- 
;iibed  by  the 
s. 
lows : 

at  the  out- 
der  observa- 
vas  admitted 
;  hospital  on 
5  and  curious 

r  is  a  bright, 
,  has  had  ten 
:d  as  is  this 
cy  to  mental 
1  was  normal 
^fancy.  She 
matism. 
ect  to  invol- 
head,  which 
■,  sometimes 
J  the  doctors 
development 
ted.  For  the 
iinds;  hegin- 
)metimes  she 
call  out  the 
w  name  she 

11, :  A  bright, 
ely,  takes  an 
en  ambitious 

occasionally 
no  grimaces, 
nimic  move- 
she  caF':  out 

!•  ;  -.lear 
:  .'Ctj  o.  f  ■;n- 


J./i    //, 


CONVULSIVE    TIC.  3 

i'nJtt?;  'T ?,  ""f  'P'"'"'  '""'"^  ^""^  unimpaired.  Exam- 
ination of  the  heart  and  lungs  was  negative  ;  the  thyroid 
gland  IS  slightly  enlarged. 

temnt?''"^""'  '^   ^'""'  f^"'"'  °*   J^-'y  ''"^^  August  at- 
tempts were  made  to  treat  the  case  by  hypnotic  su-j^es- 
;ons,  at  first  with  success,  but  subseciueiiry  witho  tiny 
impioveinent.  ' 

letfer  S^'^'^r  ^'^  ^"'  '"°"^<^'-  ^^™'«  ^he  following 
matdy         '  '"'''''  "   "'^   P*^^^^   "^   '^e    child'! 

ashamed  to  bring  her  to  you  or  to  take  her  out  of  the 
house;  ,t  IS  dreadful;  such  words  as 

me  for  M  r'  l''"^^'  ""  "'°^'''  '^"^'  ^"''  '''  '-^''"o^t  kills 
me  for  to  hear  her  use  such  words  " 

told  ILrh.''"'  ""'  ""^^'^  '°  "^""^^  ^^'  '-^S^i"  ^"^1  -a^ 
old  that  this  was  really  a  part  of  the  affection,  and.  like 

the   movements,  involuntary  in  character.     The   c liM 
seemed  more  depressed,  had  lost  flesh  and,  her  m^ U  ' 
said,  had  changed  mentally.     She  was  very  obstinate 
and  almost  invariably  did  what  she  was  told  not  to  do 
and  had  threatened  to  take  poi  She  will  say  the 

bad  words  aloud  or  mutter  them  to  nerself 

On  admission  to  the  hospital  she  was  placed  in  a  room 

by  herself,  kept  m  bed,  and  encouraged  in  every  way  S 

cease  m  king  the  sounds  and  to  stop%he  use  of\h    bad 

words.     During  the  first  two  weeks  she  improved  very 

much      I  he  movements  were  reduced  in  frequency  and 

ometimes  during  my  visit  they  would  not  be  noticed  .t 

with  [he  IvL   "'"";°"'y  '-^f'f^^'^d  the  right  arm.  which, 

ek      Thih.  7'^     '7  "P  in  a  sudden  electric-like 

alone      \        f  '"^"''''  ''°"'^  '^^'^  simultaneously  or 

a  one.     Sometimes  there  was  combined  movemen    of 

he  neck  and  chest-muscles.     The  involuntary  expres 

abo'e  a"  r'  ^'r  T^'  "^^  ^^'^-  'h«-  --tic  :.4 

above,    a   sharp  bark   was  the  most   frequent  sound 


•!    fi! 


time  past  he  has  not  felt  as  well  as  usual.     On  November  1st,  while  at  his 
supper,  m  a  restaurant,  he  found  that  he  could  not  read  the S  paper 
He  was  sure  that  this  came  on  quickly,  and  had  been  his  chief  llZj- 
ance,  as  he  was  an  ardent  politician.     He  had  no  definite  headache,  but 


tf      x:     911 

R 

1% 

■/?    ■■ 

I    ^     f- 

■;■                              ; 

:■      1 

'!<' 

).-llfe 

1  > 

«  4t  nwmuiJuil 

MgAJM      r 

■aMHJII 

'iuHR 

^^'l' 

4  O  S  L  F.  R  , 

which,  from  its   ringing   n.i.ility,  coiiKl  be   heard  at  a 
considerable  di  t;(nce. 

She  was  so  much  better  liiat  she  was  allowed  lo  get 
up  and  another  patient  was  placed  in  the  room  with  her. 
This  seemed  to  cm  :e  and  woi:)  he  ,  and  shmdy  after- 
ward the  barking  sounds  became  much  :nure  frequent, 
occurring  every  one  or  two  minutes,  aad  -I'.e  complained 
of  great  soreness  of  the  muscles  of  the  chest  and  abdo- 
JTK-n.  The  i  v>vemcnts,  however,  did  not  increase.  She 
WHS  again  pli:ed  in  seclusion  and  in  bed,  and  again 
"iipnjvement  followed,  but  she  still  barks  and  she  has 
rot  given  up  entirely  the  use  of  bad  words. 

She  i-  a  docile,  intelligent  child,  and  :;eems  anxious 
CO  get  well.  She  has  kept  a  diary,  whii  h  displays  no 
special  peculiarity.  She  writes  verses,  \s  iiich  are  not 
worse  than  those  usually  composed  by  girls  of  her  age. 

The  patient,  as  you  see,  is  a  bright,  intelligent  child, 
and  there  are  still  to  be  seen  occasional  lateral  jerkings 
of  the  head,  and  now  and  then  the  right  arm  is  elevated 
with  great  quickness.  You  have  also  heard  the  peculiar 
sharp  sound  which  she  makes  from  time  to  time,  which 
sometimes  resembles  a  hiccough.  More  commonly  it 
has  a  barking  quality,  which  is  not  nearly  so  marked  as 
it  was  some  weeks  ago,  when  usually  two  of  the  sounds 
succeeded  each  other  with  rapidity.  In  addition,  this 
child  has  presented  several  of  the  symptoms  which 
Charcot  and  his  pupils  regard  as  characteristic  of  the 
affection. 

I  have  just  spoken  of  the  emission  of  involuntary 
sounds  and  words.  The  use  of  bad  words,  for  which  the 
ingenious  expression  coprolalia  (ficcal  speech)  has  been 
invented,  is  present  in  very  many  of  the  cases,  forming  a 
feature  very  distressing  to  the  relatives. 

You  can  judge  from  the  letter  of  this  child's  mother 
how  grievously  troubled  she  was  over  our  patient's 
"slips  of  the  tongue."  She  cried  bittei'y  when  she 
told   us  of  it,  and   said   that  she  wished  daughter 


i 


"le   heard  at  a 

illowed  to  get 
room  with  her. 
sho'-dy  after- 
nure  frequent. 
»e  complained 
ie,3t  and  al)do- 
increase.  She 
;d,  and  aj,'ain 
;  and  she  has 

;eeins  anxious 
h  displays  no 
Aiiich  are  not 
dh  of  her  age. 
elligent  child, 
Lteral  jerkings 
rm  is  elevated 
•d  the  pecidiar 
to  time,  which 

commonly  it 
so  marked  as 
of  the  sounds 

addition,  this 
iptoms  which 
:eristic  of  the 

if  involuntary 

for  which  the 

ech)  has  been 

ses,  forming  a 

hild's  mother 
our   patient's 

Illy  when  she 
it':  daughter 


CONVULSIVE    TIC. 


I 


S 


dren  of  te  o!"  •'""'  ""[  ''''  "P"'"''^^'  ---'  --"  ^hil- 
the  m^vf  7  '"  f  •'"■'  ^'^'''  P-^'-^i^tently  used  words  of 
ine  most  obscene  cliaracter. 

A  second  peculiarity  of  a  similar  nnturr  is  the  rencti 
t.on  of  any  sound  or  word  heard,  for  wh.h    ie  ,'ame 

.  nd  the  word  .s  repeated  by  the  patient  so  soon  a  hea  d' 
iew  ,amr  ^  "  "  n"f  "''^"  °'^^"'--  ""^  °"  '---"a 
use!  T  '■""   "■''  '^°'"'""    '"'°  ^'^^^  hospital,  she 

but  has  not  been  a  special  feature.  This  curious  imita 
.on  of  ,n,,scular  movement  has  been  described,  no  "iy 
in  the  face  muscles,  but  i,i  those  of  the  extremities  and 
simulates  closely  those  of  the  remarkable  M  Ua  1  Use 
known  as  /././.  The  term  ,v/.>/v>../.  has  been  a  pHed 
to  this  mimicry  of  movements.  'M'i'"ea 

So  far  our  patient  has  not  p'resented  any  symptom  of 

and  hr   :??';•  "'""  ''''''  ''''■  -treme^lS  c/ 
and  he     addiction   to  poetry  could   be  so   considered 
Upon  this  aspect  of  the  affection   Charcot   lav     '  eai 
stress,  and  thinks  that  sooner  or  later  the  cases  inva  i 

mental  change  is  the  existence  of  hxed  ideas  and 
Guinon,  whose  article  in  the  n^a^o;..r/n■  Kn^J^^ 
''^"'^  ^s  the  most  extensive  on  the  subject,  describes 
hese  as  very  often  a  fear  of  impending  trouble  or  a 
ear  o  places  (a.orapMia).  In  other  instances  'there 
IS  fohepouy>]tmr  m  which  the  patient  incessantlv  de- 
mands the  reason  for  the  performance  of  even  the  sin- 
plest  actions  of  life. 

"  Folic  du  doutc-  and  the  curious,  irresistible  impulse 

fo.m  of  this  obsession  which  has  been  noted  in  some 
instance,,  is  what  has  been  termed  arithmomania  in 
which  the  patient  is  possessed  with  an  irresistible  desire 


J: 


time  past  he  na.s  not  felt  as  well  as  usual.  On  November  1st,  while  at  his 
supper,  ,„  a  restaurant,  he  found  that  he  could  not  read  the  S  pape^^ 
He  was  sure  that  this  came  on  quickly,  and  had  been  his  chief' aSy: 
ance,  as  he  was  an  ardent  politician.     He  had  no  definite  headache,  but 


o  s  r,  K  R  , 


f     '. 


*  <  .1 


'  t 


,  i 


to  do  some  special  mathematical  problem,  or  to  count 
up  to  a  certain  number  before  doin^'  a  certain  action. 

In  brief,  the  main  peculiarities  of  the  disease  are:  the 
invokmtary  movements,  the  iitterini;  of  words  or  cries, 
coprolalia,  mimicry  of  words  or  movements,  and,  in  very 
many  instances,  mental  symptoms,  chiefly  some  form  of 
obsession.  The  majority  of  the  cases  present  only  the 
first  two  or  three  of  these  features,  and  it  is  not  until  the 
more  advanced  stages  that  the  mental  symptoms  be- 
come marked. 

The  prognosis,  according  to  Charcot  and  his  pupils,  is 
extremely  grave,  and  very  few  cases  recover,  but  years 
may  elapse  before  the  onset  of  mental  symptoms.  The 
diagnosis  is  easily  made  in  cases  such  as  the  one  before 
you;  but  there  are  several  conditions  which  in  certain 
features  simulate  the  disease  very  closely.  Thus  copro- 
lalia and  the  irresistible  tendency,  on  all  occasions,  even 
the  most  solemn,  to  use  obscene  words  have  been  de- 
scribed apart  from  any  motor  phenomena.  There  is 
the  oft-quoted  case  of  the  Marquis  of  Dampierre,  who, 
from  early  youth  to  his  ninetieth  year,  involuntarily 
uttered,  even  under  circumstances  the  most  solemn,  the 
words  "  uwrdr  .'  "  and  ''foii/u  cochon  .'  " 

Still  more  common  is  the  existence,  partic'iiarly  in 
children  and  youth,  of  a  fixed  idea.  One  of  the  com- 
monest is  the  "  (ill trie  dr  foia/wr,"  which  impels  the 
individual  to  touch  certain  objects,  and  of  which  the 
great  Dr.  Johnson,  as  is  well  known,  was  a  subject. 
One  of  the  most  graphic  accounts,  probably  autobio- 
graphical, of  this  imperative  impulse  to  touch  objects  is 
given  by  George  Borrow  in  his  La7'cno;ro,  the  Scholar, 
the  Gypsy,  and  Priest^  in  which  the  practice  was  followed 
in  order  to  prevent  evil  happening  to  the  lad's  mother. 

In  many  points  the  affection  has  a  close  resemblance 
to  the  common  habit-chorea  or  habit-spasm,  with  which 
indeed  the  involuntary  movement  of  convulsive  tic  is 
identical.     I  do  not  remember,  however,  to  have  seen  at 


i 


em,  or  to  count 
rtain  action, 
lisease  are ;  the 
words  or  cries, 
Its,  and,  in  very 
y  some  form  of 
resent  only  the 
is  not  until  the 
symptoms  be- 

id  his  pupils,  is 
over,  but  years 
mptoms.  The 
the  one  before 
hich  in  certain 
Thus  copro- 
•ccasions,  even 
have  been  de- 
na.  There  is 
ampierre,  who, 
,  involuntarily 
ist  solemn,  the 

particularly  in 
»e  of  the  com- 
ch  impels  the 
of  which  the 
was  a  subject. 
Dably  autobio- 
:)uch  objects  is 
1),  the  Scliolar, 
e  was  followed 
ad's  motiier. 
;  resemblance 
m,  with  which 
ivulsi\-e  tic  is 
3  have  seen  at 


CONVULSIVE    TIC.  7 

the  Philadelphia  Infirmary  for  Nervous  Diseases  amone 
the  numerous  cases  of  habit-spasm  which  clme  ZZ 
chn.cs  particularly  to  the  clinic  of  Dr.  S.  We     Mi    hell 
a  smgle  instance  in  which  other  symptoms  d'elo.ed 

his  middle"  r"''  ""'u"'''^'  ^"^'""' '"  ^^'^•'^h  the  lad  put 
his  middle  tuiger  into  his  mouth  and  bit  it  severelv  md 
at  the  same  tune  with  the  index-finyer  compressed    Je 

time        H   T'.       ''''^  '^'^''  '^^^^'  -'"tinued'for  a    o  >g 
time,  and   had   resulted  in  the   production  of  a  thi  k 
callosity  on  both  surfaces  of  the  second  phalanx  of  hit 
hnge..     A  somewhat   similar  trick  is  reported  to  have 
been   p,aet,sed  by  Hartley  Coleridge  when  a  boy,  on Iv 
.f  I  recollect  anght.  he  was  in  the  habit  of  biting  h 
am      And  cp.ite  recently  there  was  at  the  clinic  a  girl 
mne  years  old.  who.  during  convalescence  from  choiea 
leveloped  the  curious  trick  of  first  smelling  and  then 
blowing  upon  anything  she  took  into  her  hand 

With   hysteria   the   relations  of  the   disease  are  not 
thought  to  be  very  close  by  Charcot   and    his    pupils 
rhe  affection  usually  sets  in  at  a  period  of  life  earlie; 
than  that  at  which  hysterical  symptoms  begin,  and  ver^ 
many  of  the  cases  show  no  manifestations  of  hysteria 
The  utterance  of  loud  involuntary  cries  and  anomalous" 
sounds  IS,  however,  a  special  feature  of  certain  cases  of 
hysteria  which  may  thus  present  a  resemblance  to  this 
form  of  convulsive  tie.     They,  however,  are  not  neces- 
sarily associated  with  involuntary  movements,  and  are 
usually   of  a   more   bizarre  character.     I    remember  a 
remarkable  case  of  the  kind  which  was  brought  into 
Iro.essor   Wagner's   clinic   at   Leipsic.     A  child,  aged 
about  fourteen  years,  had  for  several  weeks  uttered  the 
most   remarkable  inspiratory  cry.  followed  by  a  deeo- 
toned  expiration,  both  of  which  were  audible  at  a  -reat 
distance.     They    persisted    during   the   day  with  "each 
respiration,  but   ceased   during   sleep.     The   child  was 
worn  to  u  skeleton. 
Dr.  Gapen,  of  Omaha,  brought  to  the  hospital  last 


■I 


..J 


time  pa-st" he  hWnot  felt  as  well  as  usu« '      On  >,  ovember  1st  whiJP  nt  k;= 
supper,  .„  a  restaurant,  he  found  tl,.  '  ■  corJd  notTea  1  .'  3  dlilv^^^^^^ 
He  was  sure  that  this  came  on  quickl,,  an.I  l:ad  bee^,  his  S  amfov 
ance,  as  he  vas  an  ardent  politician.  "^He  had  no  <S  ui^  h  al^CS 


II 


'  < 


8 


CONVULSIVE    TIC, 


year  a  phonograplv  cylindfr,  on  whirh  was  recorded  a 
most  remarkable  hysterical  cry  which  the  patient,  a 
young  girl,  had  been  in  the  habit  of  uttering  for  many 
months,  and  which  was  loud  enough  to  be  heard  at 
a  distance  of  several  blocks.  I'hese  cases,  howover, 
usually  present  other  features  which  make  the  diagnosis 
clear. 

As  was  the  case  in  this  patient,  the  afifection  begins  at 
an  early  period,  in  the  majority  of  the  cases,  according 
to  Guinon,  from  the  sixth  to  the  twelfth  year.  They  are 
commonly  regarded  as  chorea. 

An  hereditary  neuropathic  taint  has  been  present  in 
many  instances. 

We  have  treated  this  child  in  the  hospital  by  secb'sion 
and  rest  in  bed,  and  have  made  moral  rathe,  man 
physical  efforts  to  improve  her  condition.  She  is  cer- 
tainly better,  parti<  ularly  in  the  matter  of  the  use  of  bad 
words. 


SfttJ 


vas  recorded  a 
the  patient,  a 
ring  for  many 
:o  be  heard  at 
ases,  however, 
e  the  diagnosis 

ction  begins  at 
ises,  according 
;ar.    They  are 

;en  present  in 

al  by  secli'sion 
\\  rathp.  man 
.  She  is  cer- 
the  use  of  bad 


,„.      ,  Extruded  from 

rho^Honn  .Journal  of  tho  Medical  Science,  for  March,  IH-U, 


A  CASE  OF  SKX.Si 


V  AI'IIAS[A-\\'()li|,  |5,jxDXE,S8  WITH 
JlK.MIA\()l\si,\ 


l'>v  WiLMAM  (>su:r,  M  D 


HAI.TIMcpid' 


S    HOPKINS    l'N|\  K8S1T1-, 


This   rme  illustmtes  the   following  ..(unts-    Cn  Tl.o    ,.      •  .• 
.ord.bli.dness  with   disease   ...   the     uL^L  i^   .^ '^'7;; 
narapha.s.a  which  so  often  a.eompanies  this  conllitioa;  ,!3)  Thetl 

>ce  o   hemianopsia  fron.  interrnption  of  the  fibres  of  the  op      radl 
tiun,  wifliout  disease  of  th.  occipital  lobe 

Clinical  SvmiXHY. -Inability  to  read  a  newspaper  the  first  vnnv 
t^>n;  t,,ncal  worcl-mndne.,  retention  of  intelligent  iLln,;  ZpZL 
0  n^ord.  and  .enteure.-parapka^ia;  ri.kt  ho^nonyrnousheJn^^. 
no  paralyse ;  pers.tenc.  of  this  condition  for  over ,  ,nonU.,  ,oitk  radml 
loss  of  mnsrnlar  strength  and  n.ntal  po.er.  For  ^A/  .,-.  •  jj"^ 
death,  paralysis  of  right  arm  and  leg.  ^ 

</.;lr™r"'''  ^7'^'-Y;^^'-^^--«'^"«  ^^<^Stening  m  the  left  henusphere  of 
unce,ashe  •aa  an  ardent  politiouuL   ^He  hu.^       defrnit'heailirbJt" 


11 


OSl.KH.     SKNSOin      A  1' NASI  A. 


conipliiiihd  of'ii  (liHiisc.  iiiuiisyM'iiHatiMii,iiii(l  soiuotinics  pljiml  liis  Imiid 


i: 


(/  pd^t  :i 


hi 


;    , 

.  i 

i 

1  >■• 
i   , 

i  1 

!  1   '  f 

^j 

f 

I:!. 


I 


lipuii  his  lictui  (^iiyiii;,',  "  It  in  all  wroii;!;'  Iiorc, 


l'rcHV)it 


ilKloii 


cnnititioii  :  Vij^Droiiw-lctokiii^'  iiiin  lor  his  ago ;  I'acc  intd- 
iif,'ciit  ;  siicaUs  clearly  ami  rapidly,  with  (Kra.-ioiial  intcrniptioiis ;  no 
paralyse;  inovciiu'iits  of  thf  aiin.s,  k'jr.s,  and  Caco  pcrtivt  ;  no  los.s  of 
sciiHation  on  cither  sidi- ;  no  inco.irdination  ;  ho  j^taiids  well  with  hiseyes 
shut ;  nlloxfs  noinial. 

Speech:  Thonj,di  he  speaks  clearly  niul  intelliirontly,  and  utters  some 
sentences  without  internipi  ion,  rcpiyiiijr  promptly  and  lluently  to  (hics- 
tions   and    evidently   undert^tanding  evcrvthin-,', 'there    is  very  distinct 
speech-disliirhance;  thus,  for  some  time  he  could   not  give  the  address 
of  his  residence.  He  says  he  knows  where  it  is,  hut  could  not  prommncc  it 
He  told  thelirst  name  of  the  man  with  whom  he  lived,  hut  could  not  say 
the-econd.     lie  could  not  name  his  own  occupation,  hut  said,  "  Keen 
keep,  keep.     Oh,  you  say  it  lor  me."    When  told— hookkeeper-he  re- 
peated It  distinctly.    He  occasionally  misplaces  words.    In  referrin<'  to  a 
wetting  which  he  had  spoken  of,  he  said,  "  Deliherate  attacks  of  wet  dns.  " 
VV  hen  a  jirmted  or  written  |>age  is  i)re.-ented  to  him  he  does  not  appear 
to  comprehend  the  words.     The  word  Philadelphia  at  the  head  of  a  hos- 
pitiil  hlank,  he  rea.l  P,  r.  i,  n,  g,  r,  e,  k.      VVIu  n  told  that  it  was  Philade'l- 
pliia,  he  replied,  "  Oh,  certainly  it  is,  I've  known  it  tor  sixty-five  years  " 
His  age,  72,  written  on  a  slip  of  paper,  he  read  21;].     He  did  not  recog- 
nize tlie  words  "Cievelaiid  and  Harrison"  at  the  top  of  a  newspaper  co- 
lumn, hut  when  read  to  him,  .said,  "  I  know  all  ahout  them  "  and   he.rau 
making  some  very  shrewd  observations.  He  can  write  his  name,  but  say.'} 
that  since  his  lailure  to  see  he  does  .so  with  dithculty.    Pie  writes  as  well 
with  his  eyes  shut  as  when  they  are  open,  but  does  so  with  hesitation 
He  wrote  the  name  of  the  hospital,  and  the  words  "  Philadelphia  Ke- 
cord.       He  could  not  read  the  words  of  his  name  after  he  had  written 
ttiem.     He  names  objects  held  before  him  (jiiite  readily. 

Dr.  (le  Schweinitz  examine',  the  eyes,  and  reported  the  presence  of 
right  lateral  homonymous  hemianopsia.  Dr.  de  Schweinitz's  renort  is 
hero  annexed :  '■ 

Right  eye:  An  oval  optic  disk,  with  the  scleral  ring  plainly  followed 
all  round,  and  both  superficial  and  deep  layers  very  gray  ;  the  veins  full 
and  dark  the  arteries  unchanged  in  size;  a  fine  retinal  haze  veiled  the 
upper  and_  lower  margins  of  the  disk ;  there  were  no  splotches  or  hiem- 
orrhages  m  the  general  eye-ground,  and  no  changes  in  the  macular 
region. 

Left  eye:  An  oval  optic  disk,  with  well-marked  scleral  ring,  more 
visible  than  on  the  opposite  side,  because  the  retinal  haze  seen  in  the 
opposite  eye  was  less  apparent.  A  similar  appe,  ance  of  the  retinal 
circulation  and  an  absence  of  gross  changes  in  the  retina  and  choroid  • 
the  disk  was  also  gray,  but  not  so  devoid  of  color  and  capillarity  as  that 
upon  the  opposite  side.  ^ 

Xovnnlwr  21,  IS-SS.  Patient  was  admitted  to  hospital  with  no  essential 
oliange  in  ius  condition,  thougii  he  did  not  seem  to  misplace  words 
so  often  He  could  not  say  his  age.  72,  but  said  "  (!0  an.l  10  above 
that  and  2  above  that -that's  72."  He  knew  the  day  of  the  week  and 
o  the  month,  and  what  year  it  was.  He  was  asked  how  many  years 
after  Burns  s  'joatli  he  wius  born,  and  said  5000,  but  a  once  corrected 
himself  and  said  "  >,o,  no ;  I  do  not  mean  that— twenty-five  "    The  state 


Iiu-eil  his  hand 

! ;  f'aof  iiitcl- 
■rniptioiis ;  no 
•I  ;  111)  losM  of 
I  with  hiseyt'8 

li  utlor.s  Hoiiio 
ic'iitly  to  <|iic,s- 

Vfi'y  distinct 
e  the  address 

pronounce  it. 

could  not  say 

said,  "  Keep, 
L'cpcr— he  ro- 
rcferrini^  to  a 
of'wet  drcM.s." 
OS  not  appear 
lead  of  a  Iioh- 
was  IMiiladel- 
ty-tiveyeaiH." 
lid  not  recog- 
iiew.spaper  co- 
,"  and  lieiraii 
inie,  hut  says 
ivrites  as  well 
h  hesitation, 
adelphia  Ke- 
i  had  written 

3  presence  of 
;z's  report  is 


Jily  followed 
-he  veins  full 
:e  veiled  the 
ihcH  or  hteni- 
the  macular 

1  ring,  more 

seen  in  tiie 

the  retinal 

md  choroid  ; 

iirity  as  that 

no  essential 
place  words 
id  10  above 
le  week  and 

many  years 

-•e  corrected 

The  state 


O^l'HH,    .SKN.Soiiv    AI-ilASlA 


8 


of  word-hlindness  iitrsi^i,,,!      rt 

was  di(li,.nlt  to  ir.^t  hin,  "'  wri  i  •     "'"'     *  '"''^''''"  (">-^.Tvcr."     It 

*rom  dictation  ,;.,  ,,,,  |.,,,,|, ,,;,;;',;; ,,.''  "''J  ""P'-Hihle  for  him  ,o  ,io  so 


The  oval  oiilliiii"  nf  (.,i,.|i  li,,,,,.,,   ;.,  >i 

point     There  i.  deei.Iod  .ontn '.ti„„  o/^M   t.^     ' ''"  '"."'f ,'  ^"'""""^  *''"  "-"g- 
the  right  si.lo,- that  is,  upon  th. -i,io  nnno  LT  ,  "'''''  """*'  "^'"'"-"l  ",„m. 

-r;:itJ;.::;^::u;;-!;^.:^'!;3;!-'^:;-  He 

not  care  to  talk  with  (he  otiu.-    atie    s      \V  l'''*l''';'T  ''""^^'  '""'  ^Ji'l 
generally  placed  his  hand  upon'  4,  Zl        '"^^l'  ''"^^'  '"^  ^''^''  ^"^ 

plirase  "  All  wrong  here."  ""''  '^'P^^ted  several  times  the 

Rth    Thn  f  11      •     ^^^''"  •'".^'^  "*'  has  voniitci    frcriueTitk- 
er/<    Ihe  followniirnote  was  ni'ido-   "  T.,IL- .  i       *■     .     •  " 
l>gentlyaml  plainlv  at  first    hner  ..  1.  '''' ^'''''''>:-    .%Hks  intel- 
understand  what  hJstates      \     ulS>„.l        i    '''I''"'  '^  '"'^  '>'^^'"lt  to 
tlie  ha.Hls  is  ef|i,al.     lie  walks  w'"'  '"■",''""  ''^'^'i^^-     ^he  grip  in 
there  is  no  actlal  ,,arulvsN  '         ''''  "  ''^"'^'"■'"^'  ^""<^''"'g  g"it,  tIm'ugE 

t^BSBi^^^?^^ -■■■ 

for  several  days;  no  paraksis  f  oti  n  n-of  ^  '?•  ^''''' t'''  ■"  ^^^ 
understand  and  usuallv  answers  co  Teot Iv  f  ''"f ''*'"•  He  seems  to 
noted,  he  would  not  giVe  1  i? a  'e  con-e^^^^^^^^  "•'^''''  "'  ^^'^  frequentlv 
first  spoken  to,  his  speech  is  cleaf  am  iS'.  ^'"'f'.f "'''  '''^'''''-  ^^'''«» 
becomes  very  incohcVent  an,l  m  n  ,  T  1' i"  'Y'  '"  ^^  ^'''''  "'inutes 
and  restless  at  night  irettin-^  o  ,  *  1^'  i  V  ''^  '""  ''^^^'"  vervnoisv 
^>"  the  12th  the  notfw  ^"  Ke  .,  S  ir;  "'"^'"^  '^'V*"^  ^'^^  w«rd.''^ 
"o  paralysis  :  talks  without  diffK^v  •!::.''"''  '""•''^•'""  =  ""  ^'^^'^  = 
otliers  m  a  senseless  manner.   8avs  com)  :  f  j*^  ;ir^^'«"«  ^O'-'-eotly, 


distil  rbaii 


ce  of  scnsati(m. 


■  C(mtinually  '  Lord,  h 


dav 


On  the  loth  the  note 


,  liave  mere) 


N( 


Tl 


was 


ns  morning  could  not  b 


■  Has  I 


l)een  very 


to  the  left,  but  sonieti 


le  roused 


H( 


of  the 


CV( 


Pupil 


mes  moves  it  to  the  riirjit.     X 


wakeful  for  the  past  two 
les  with  his  head  turned 


TIT      I     -  n  ,        1  ^  t'  uui  an- 
Muscles  of  the  right  side  of  fac 


piis  equal  and  of  medium 


SI 


conjugate  deviation 


•e  seem  to  act  as  well  as  th. 


ze  ;  react  feebly  to  light 


'' 


I 


ose  on  the  left. 


m 


m 

L 

1 

HI 

I'll 

1 

■MB'/jit :  :m  , 

fii 

mji^:k 

^^^^^^&V'^ 

m 

m 

is  . 

*  OSLKR,    SENS,ORY    APHASIA. 

the  last  twenty-four  lioi.rs.     He  moves  tlie  ri-l,t  ley   but  when  Vftolh 
falls  more  rapxlly  and  with  n.ore  dead  weio-ht^than  t'he       ,e        H  1   i 
a  senu-eonnuose  condition.     There  are  loud  bronchial  ra  V'     He  4nk 
and  died  on  the  aftei'noon  of  the  IfJtli 

Pod-morfem   Jive /loui;  after  death  :   ]}odv  nioderatelv  well-nourished  ■ 
no  ngor  mortis  ;  calvaria  thick  and  svmmotrical.  '  nourished  , 

f.innT  ''"''  "'T"^V"V'  ''''y  ^Josely  adherent  to  the  skull ;  sinuses  con- 
tained  recent   blood-clots;  a    moderate   amount   of   Hui.i    cscS   on 
removal  of  the  brain.     At  the  base  the  membranes  were  i  o  ma       T 
caroti.ls  were  stifl  and  atheromatous;  vertebral  and  basilar  arteries  in 
the  same  state.     Xerves  at  the  base  normal.  aiteiies  in 

Cortex  :  Pmin.jderately  injected;  the  posterior  part  of  the  left  hemi 
sphere    ooked  fuller  and  the  c<.nv.,lutions  were  paler  t.u   on  thVri 
side      Ihis  was  particularly  marked  on  the  parie  al  and    enn  omM  if 
portions  of  which  look  softened.     More  accuratelv  deteriniZ     v       ht 
and  touch,  the  suj.erticial  soft  areas  were  as  follows  •  ^    ^ 

^^1.  The  entire  supra-marginal    and    the   lower  ,)art   of   the   angular 

].Mr;Jr V''°ft"'''""  ,'"V^  "^'.  ^^''  ^""'t  '"'''  ^^^^o"'l  temporal  o-yri   which 
bulge  distinctly,  and  the  veins  of  which  are  much  distended"' 

o.   Ihe  two  annectant  convolutions  joining  the  first  temporal  -n-rus  and 
ofVvivi'us      "'"^••^'"^-"^-  •-'>•  --'"'^  ^^fter  separatioi/  of" 'tk^fisj;.;.' 

Though  these  i)arts  were  softened  and  contrasted  by  touch  in  -i 
marked  nianner,  with  the  rest  of  the  brain,  superficially  T  I  id  L' 
look  very  different,  and  were  only  a  little  paler  ii  color  ^ 

the  i\'ei"indlSonr  "iT  '''"'  '"^  V''''  '^''  "P^"  '"''•'  f«"»^l  ^^^  to 
.,n!l  .1  '^f'"''l^'^['o"^;  Jlievpresente.l  occasional  flakes  of  atheroma 
and  recent  soft  blood-clots,  but  no  thrombi.     The  posterior  cerebri 

7Z     T\  T:         f  ''^''?'  ^'«"tricle  was  not  distended  on  Uie  left 

side     riie  caudate  nuclei  and  thalami  looked  normal.    On  the  ou  er  w'd 
of  theleft  ventricle,  just  at  the  pointof  (iivergence  of  thede  cend  i"'  and 
posterior  coriiua,  there  was  a  grayish- white  su'^^lling,  preseSg  conSste 
bloodvcs.sels_here  and  there,  an<i  which  looked  lO  L  regi  n  oTtluom 
bot.c  necrosis;  behind,  it  exte«de<l  into  the  posterior  hoCante  ioi-y 
It  did  not  reach  the  pulvinar.     The  epeiulylna  of  the  ,.«  t.'   or  ho  n 
was  soft  but    he  deeper  white  matter  of  the' lingual  gt.-       u  1  ofX 
convolution  at  the  junction  of  the  parieto-occipital  and  cab  u^be  fi    u res 
was  not  mvolveil  to  any  depth.  -^ '-"'^■innL  nasuits 

The  organ  was  inject'ed  with  and  hardened  in  Miiller's  fhiid  and  then 
horizontal  sections  were  made. 

Section  1,  half  an  inch  above  the  corpus  callosuni 

Ihe  wliite  matter  of  the  centrum  ovale  on  the  left  side  presented  a 
slight  red. lish-browii  color  in  the  Hbres  of  the  parietal  lobe.' 

hection  2,  at  level  of  the  corpus  callosum 

An  area  of  softening  in  the  po..terior-external  r.art  of  the  centrum 
ovale  o    about  four  centimetres  in  antero-posterior  exten       Externa 
this  section  passed  through  the  angular  gyrus,  the  gray  latte^f  which' 
was  hrm,  but  the  white  matter  was  unifbnnly  softened    '"''"''''*  '''"'''' 

becti(m_ ;!,  at  the  level  of  t 

The  softening  occupied  a  1 


ion  .,,  at  the  level  of  the  middle  of  the  basal  .raiiLd 


irije 


la. 


area  between  the  posterior  horn  and 


:'oine  on  within 
t  when  lifted  it 
lier.  He  is  in 
es."     He  sank 

»eIl-noiirished ; 

1 ;  sinuses  con- 
1  escaped  on 
normal.  The 
lar  arteries  in 

the  left  heini- 
n  on  tiip  right 
inipora!  lobes, 
ined  by  sight 

the  angular 

I  gyri,  which 

d. 

ral  gyrus  and 

f  the  fissure 

touch,  in  a 
ciiCy  did  not 

found  free  to 
of  atheroma 
ior  cerebrals 
issing  to  the 

on  the  left 
le  outer  wall 
cending  and 
ig  congested 
n  of  throm- 
I,  anteriorly 
storior  horn 

and  of  the 
rine  fissures 

d, and  then 


presented  a 


he  centrum 
Sxternally, 
Br  of  which 


s ]•:  N  s ()  i{  >' 


horn  and 


-ecti(,n  4,  passing  through  the  outer  tliird  of  the  left 


crus. 


tM^ 


Tranaverso  section  of  left  hemi«r)Iif»ro  »,..;„  .i 
showing  the  area  of  .oftenin,r  P 's  ,|  •  '^7^'^"^'  -W.ra.narginal  convolution, 
N  caudate  nucleus ,  0.  J7.,  tail  of  ca.i.late  n'uclou,'-  V>U  ''ct  ^^■'  '''"'T"'^''  ""«'«"« ••  «• 
optic  thalamus;  P.  0.,  „arioto-occi,.,tal  f|,su"e  p  ,  o  "  T'""  '""""'^ '  ''^  "- 
fissure  (?)  ;  Sup.  Ma.g,,  supra-n.arginal  ,yZ.  '       "''"'"'''  ^^"^'"-^'^'PiM 

inul::n!!:;"!;;!i;:3i;;Sonu.nV'^ 

the  fibres  behind  the  <;  d^I^  S  IK;'"  :;''r''^''  ""1^  f  '"^'"'^'•"^ 
caudate  nucleus,  where  it  „.,ss(  d    n  .','•-   ""''  *''^'  ^'''^  »^'  the 

orly,  the  white  f  bres  of  I  e'  c;  it  .1.  '  '^'"'T'^^  <'-•>'"•  Posteri- 
the  softening  reach.ed  ,  ho  en,  K  Jn  V  ""^  '".'■'*'^'*^^*^-  ^''^t^'nally, 
dark  in  color.  Ex  en  a  ly  in,'/'  '^  FT''":  '-'•'>-  ^vhich  was 
matter  of  the  ccnv^.lutions  '  ''"'  ''"'  "''^  '"^■"'^'^"  ">«  gray 

crr^emS'imT"'^'  "'^  '^"^'^"'="-  "-'--'  ^he  thalanu.s,  and  the 

.  S^S';r:;tS;:^^;::r,;;,r;;ri'^;:^^!-  ^^^r-  involution. 

second  tc.nporal  gvri  ^     ''      '""''  "^  ^''^  ''"'•''  ""*'  ^he  base  of '  the 

Tirif?S'ra'U!r::;!;;:vt'^? '"'''  ''^'"'^'"'^'-'^  --  '-•-^'• 

patches  of  extrav  sS;,;    '  '    m2±^;;|:r"T"'''  '"^^'•«1---1   -i^li 
The  vessels  were  c-pf..  u  J  .    !.'  t"'J'^  be.ord.nary  necrotic  chansre. 


many  (»f  the  small 


but 

part  of  the  temporo-sphenoidai  7o"be"'t? 


i^vii ;  no  miliary  aiieiiri.- 


ms  were  found, 


iller  ones  were  blocked  with  dirombi.     At  the  1 


unusually  firm.    The  branches  of  th 


lie  margin  of  softened 


The  d 


posterior  cerebral  art( 


ower 
area  was 


rawing  was  made  from 


■I'V  wei'e  free. 


portion  of  the  supra-marginal 


which  passed  through  the  1 


ection 

gyrus,  at  half  an  inch  from  t\ 
2 


ower 


le  terniina- 


I- 


6 


m 

1  ! 

OSLER,     8EXS0UV    APHASIA. 


on  of  the  Sylvan  fissure.  The  softening  here  ^va.  more  superficial  than 
at  any  other  po.nt  an,l  seen.ed  to  involve  the  grav  matter  In  ti>e  pos- 
terior part  of  the  first  an.l  .<eeond  temp„ral  the  softening  reached  to  he 
gray  n.atter,  but  did  not  enter  it.  In  the  section  innn  whTc^l  e  draw 
ing  was  taken  a  deep  fissure  is  seen,  which  crossed  the  he.nis  >  L  Td 
seemed  to  separate  the  parietal  and  occipital  lobes.  The  ang  dar  gyrus 
hes  at  a  higher  leve  than  shown  in  the  section;  the  white  Ltter  of  i 
was  softened,  but  the  gray  looked  very  natural.     The  drawino  is  an 


:|   ' 


^'rU 


erficial  than 
In  the  j)08- 
ached  to  the 
!h  tile  draw- 
isjihere,  and 
gular  gyrus 
matter  of  it 
iwing  is  an 
acing-paper 


CL  HI 


n,  .  "'^  WILLIAM    OSLEIl,   M  D 

rojessoroj  M„iwme  ,„  the  Johns  HopUins  University, 
nor  country,  but  whose  work  is  in  the  world      T  e 

t:l:ti  Zrv  t  ^''^^-^ '« ^^^^  wirustttrr; 

been  able  to  efface^'t  ^a's  TeLZ^el  tl^X 

not  of  th.8  country,  not  of  our  blood  -  whose  liie  ha. 

special  work  has  revolutionized  the  science  o   Ted? 
cine  who3      enius  has  shed  lustre  upon  our  craft 

j;f^riooL!;sx^nru^;fs-.jr 

00  after  a  long  enslavement,  ecclesias  ical  ami  So' 
sophical.  received  its   eniancipation.     Forsak!n|  the 


^K   f// 


BALTIMORE 
JOHN    MURPHY    &    CO. 

I89I 


^'^^ 


1 

tion  of  th 

at  any  ot' 

terior  par 

";  < 

gray  niati 

i  1  ■ 

ing  was  tj 

seemed  to 

lies  at  a  1: 

iM 

was  softe 

P 

exact  rep 

L          T             1 

upon  the 

traditions  of  the  elders,  and  scouting  the  Sliibboleth  of 
schools  and  sects,  she  has  at  last  put  off  tlie  garments 
of  her  pride,  and  with  the  reed  of  humility  in  her 
hand  sits  at  tlie  feet  of  her  mistress,  the  new  science. 
Aot  toany  one  man  can  this  revolution  be  ascribed: 
the  Zeit-geist  was  potent,  and  like  a  leaven  worked  even 
m  unwilling  minds ;  but  no  physician  of  our  time  has 
done  more  to  promote  the  change,  or  by  his  individual 
efforts  to  win  his  generation  to  accept  it,  than  Rudolf 
Virchow. 

And  now,  as  the  shadows  lengthen,  and  ere  the  twi- 
light deepens,  it  has  seemed  right  to  his  many  pupils 
and  friends,  the  world  over,  to  show  their  love  by  a 
gathering  in  his  honor,  on  this  his  seventieth  birthday. 
To-day,  in  Berlin,  a  Fest  has  been  held,  in  which  sev- 
eral hundred  members  of  the  profession  in  this  and 
ot.ier  countries  have  been  participants,  as  subscribers 
to  the  fund  which  was  organized  for  the  occasion.     It 
seemed  well,  also,  to  his  pupils  who  are  teachers  in  this 
university,  and  to  others,  that  the  event   should    be 
marked  by  a  reunion  at  which  we  could  tell  over  the 
story  of  his  life,  rejoice  in  his  career,  and  express  the 
gratitude  which  we  on  this  side  of  the  Atlantic  feel  to 
the  great  German  physician. 

Let  me  first  lay  before  you  a  brief  outline  of  his  life  : 
Kudolf  Virchow  was  born  October  13,  1821,  at  Schi- 
velbein,  a  small  town  in  Pomerania.  Details  of  his 
family  and  of  his  childhood,  whidi  would  be  so  inter- 
esting to  us,  are  not  available.  Educated  at  the  Gym- 
nasium in  Berlin,  he  left  it  at  Easter,  1839,  to  begin 
his  medical  studies,  and  graduated  from  the  University 
of  that  City  in  1843.  The  following  year  he  became 
assistant  in  pathological  anatomy  to  Froriep  ;  and  in 
1846  he  was  made  prosector,  and  in  1847  a  lecturer  at 
the  university.  In  1849,  on  account  of  bis  active 
participation  m  the   political  events  of  the  previous 


the  Shibboleth  of 
off  tlie  garments 
f  liumility  in  her 
,  the  new  science, 
tion  ho,  ascribed : 
aven  worked  even 
Li  of  our  time  has 
■  by  his  individual 
3t  it,  than  Rudolf 

,  and  ere  the  twi- 
his  many  pupils 
V  their  love  by  a 
^entieth  birthday. 
3ld,  in  which  sev- 
isioa  in  this  and 
ts,  as  subscribers 
the  occasion.  It 
■e  teachers  in  this 
jvent  should  be 
uld  tell  over  the 
and  express  the 
)  Atlantic  feel  to 

utline  of  his  life  : 
3,  1821,  at  Schi- 
Details  of  his 
3uld  be  so  inter- 
Lted  at  the  Gym- 
,  1839,  to  begin 
a  the  University 
year  he  became 
Proriep  ;  and  in 
■<47a  lecturer  at 
t  of  his  active 
of  the  previous 


K   II 


3 

year  he  was  dismissed  from  his  university  positions 
and,  as  he  mentions  was  onlv  mit  grossen  beschZi 
i":f  «/-"^!'f 'v'-gHy  in  fact  hv  fhe  eXrt    of    le" 
profession  of  Herlin,  and  particularlv  of  the  medicll 
societies.       n  August,  184-..  he  received  a  calHo  tlie 
cha.r  o    patho  ogical  anammy  at  Wiii-zbur",  a  po.it    n 
which  he  held  until   1856    when    Iw  H 1"       f"?'""" 
vote  of  fl.ft  fonnif.,   ,        "'   ^"*^"'   "y  f'le  unanimous 
vote  or  tlie  taculty,  he  was  recommended  for  and  re 
ceived  the  appointment  which  he  still  hoir'namelv 
professor  of  pathological  anatomv  at  Be  li     'Sf£ 

i'S   whl  h  noV-""-'^''^'   ''''''''^  His'-cefehrTtec 
■Tk  '      ,  ^^^  '"  ■'«  one   hundred  and    twentv 

e.gh  h    volume    is   the  greatest   storehouse   of   fa  £ 
in  scientific  medicine  possessed  bv  us  to-day. 
life  wl;^  W  ;;;l^^;:'  ''"  ""''^'^"^^"''  <l-«'  P-ceable 
As  an  illustration  of  the  successful  pursuit  of  vari 
ous  callings,  Virchow's  career  is  without  para  le'n 
our  profession,  and  this  many-sidedness  a< Ids      eat  v 
0  the  interest  of  his  life.     Dr.  Welch  will  snJak  of 
us  special  labors  in  t!ie  science  of  patholo.^-    a  LTher 
aspe.:^s  wi  1  be  considered  by  Dr.  Chew  aid  Dp, 'd. 
enwa  d.     I  propose  to  indicate  briefly  a  few  trai     iu 
his  life  as  a  man  of  science  and  as  a  ciiizen 

From  the  days  of  the  great  Staireirite,  who    if  he 
never  practise.!  medicine,  was  at  least    Li   asdepiad 
and  an    anatomist,  the  intimate  relation   of  medicine 
with  science,  has  in  no  way  been  better  shown  thaiTn 
the  long  array  of  physicians   who  have  become   dis- 
tingu.shedin  b  ological  studies.      Until   the  gradua 
d.fterentiation  o    subjects,  necessitated  by   Uif  moid 
growth  of  knowledge,  the   physician,  as  a  Tatlr  oi 
course   was  a  naturalist;  and  in  the  present  elf  om 
Galen  to  Huxley,  the  brightest  minds   of  the   uvoZ 
B.on  in  all  countries,  have  turned  towards  s  ienc^as  a 
recreation  or  as  a  pursuit.     Alas!  that  in  the  pTe  ent 


Ul 


BALTIMORE 
JOHN     MURPHY 
I.  8gi 


&    CO. 


t  •    ' 

'     i  4 

» ■  . 

f 


tion  of  th' 
at  any  otl 
terior  par 
gray  mati 
ing  was  tj 
seemed  t(j 
lies  at  a  li 
was  softei 
exact  rep 
upon  the i 


J      f 

i 

:    1 

1 

( 

1 

1- 

1 

generation,  with  its  strong  bent  toward  specialism,  this 
combiniition  seems  more  and  more  ini{)Ossil)le.  We 
miss  now  the  quickening  spirit  and  the  wiser  insight 
that  come  with  work  in  a  wide  lield ;  and  in  the  great 
cities  of  this  country  we  look  in  vain  among  prac- 
tising physicians  for  tiie  successors  of  Jacob  Bigelow 
of  Boston,  Holmes  of  Montreal,  Barton  of  Pliiladel- 
pliia,  and  otiiers  —  men  who  main^MJaed  in  this  matter 
an  honorable  tradition,  whose  names  live  in  natural 
history  societies  and  academies  of  natural  science, 
in  the  founding  of  which  they  were  mainiv  instru- 
mental. 

In  anthropology  and  archicology  the  name  of  Rudolf 
Virchow  is  almost  as  well  known  as  it  is  in  medicine. 
Very  early  in  iiis  work  we  find  evidences  of  this  bent 
in  the  memorable  studies,  now   forty  years  ago,    on 
Cretins  and  on  the  development  of  the  skull.   ''Not  a 
year  has  passed  since  that  time  witliout  some  notable 
contribution  from  him  on  these  subjects ;  and  those  of 
us  who  know  only  his  professional  side  may  well  mar- 
vel at  the  industry  of  the  man  whose  name  is  quoted 
and  appears  in  anthro|)oIogicaI  memoirs  and  journals 
as  often  as  in  our  technical  works.     In  recognition  of 
his   remarkable  labors  in  this  department,  a   special 
anthropological  institute  was  organized  in  1881,  on  the 
occasion  of  the  twenty-fifth  year  of  his  professoriate. 
In  1884,  on  returning  to  Berlin  for  the  first  time  since 
my  student  days,  I  took  with  me  four  choice  exami)le8 
of  skulls  of  British  Columbian  Indians,  knowing  well 
how  acceptable  they   would  be.     In    his  room  at  the 
Pathological  Institute,  surrounded  by  crania  and  skel- 
etons, and  directing  his  celebrated   dieuei\   who    was 
mending  Trojan  pottery,  I  found  the  professor  noting 
the  peculiarities  of  a  set  of  bones   which   he  had  jus" 
received  from  Madeira.     Not  the  warm  thanks,  nor 
the  cheerful,  friendly  greeting  which  he  always  had 


--X    f/, 


d  specialism,  tliis 
im{)08sil)le.  We 
1)0  wiser  iuaiiilit 
and  iij  tbe  great 
aiii  aiHoiif:;  prac- 
:'  Jacob  liigelow 
ton  of  riiiiadel- 
ed  in  this  matter 
i  live  in  natural 
natural  science, 
3  maiiiiy  instru- 

'■  name  of  Rudolf 
t  is  in  medicine, 
ices  of  this  bent 
years  ago,  on 
e  skull.  Not  a 
it  some  notable 
ts ;  and  those  of 
)  may  well  mar- 
name  is  quoted 
rs  and  journals 
1  recognition  of 
ment,  a  special 
!  in  1881,  on  the 
is  professoriate. 
i  first  time  since 
choice  examples 
*,  knowing  well 
lis  room  at  the 
crania  and  skel- 
•ener,  who  was 
)rofeH,sor  noting 
ich  he  had  just 
'm  thanks,  nor 
he  always  had 


for  an  old  stu-^ent,  pleased  me  half  so  much  as  the 
prompt  and  decinye  identification  of  the  skulls  which  I 
had  brought,  and   us  rapid  sketch  of  the  cranial  char- 
acters of  the  ^orth   American  Indian.     The  profound 
expert,  not  the  diletant^  student,  has  charactiriz  d  all 
o    Ins  work  m  tins  line.     Even  an  enumeration  with  a 
bref  report  of  Ins  published  writings  in  anthropologi^ 
cal  and  archaeological  subjects  would  take  more  time 
than  has  been  allotted  to  me.     Of  his  relations  with 
hchl.emann  I  must  say  something,  which  I  could  not 
do  so  well  as  in  the  words  used  by  his   friend.  Dr. 
Jacobi,  ten  years  ago:  "Schliemann,  by  whose  mod- 
ern wuchcratt  holy  old  Troy  is  just  leaving  its  tZb, 
nvi  ed  Vuchow  to  aid  him  in  his'work  of  discovery  o 
he  buried  city.     He  went-  partly  to  aid,  partly,  as 
he  says,  to  escape  from  overwhelming  labors  at  liome 
—  only  to  be  engrossed  in  just  as  hard  work,  though 
of  a  different  nature.     In  regard  to  the  latter,  Schlfe- 
manns  recent  book  on    '  Ilios  '   contains  some  very 
interesting  material.     But  what  has  engaged  my  atten- 
tion  and  interest  most  has  been  to  observe  the  humanity 
and    nidefatigability    displayed  by  the   great  man    J 
the  service  of  the  poor  and  sick.     To  read  of  his  con- 
stant, practical  exertions   in   behalf  of  the  miserable 

s!!'"  r" ''  "'--'''^'.;'-  he  taught  the  -zg^i 

the  efhcacy  of  chamomile  and  juniper,  which  erow 
about  them,  unnoticed  and  unused,  in  rare  abundance; 
how  a  spring  he  laid  open  for  archaeological  purposes 
has  been  called  by  them  '  the  physiciat's  '  and  is  be- 
heved  to  have  beneficial  effects;  how  he  was,  on  leav- 
lug  the  neighborhood,  loaded  with  flowers,  the  only 
thing  they  had  and  knew  would  please  him,  hi 
charmed  me  intensely.  To  admire  a  great  man  for 
his  professional  labors,  eagerly  undertaken  and  suc- 
cessfully earned  out,  is  a  great  satisfaction  to  the 
scientihc  observer;  to  be  able  to  love  him,  in  addi- 


BALTIMORE 

JOHN    MURPHY    &    CO. 

1891 


.:^:.  # 


I. 

tion  of  th 

at  any  otl 

i 

terior  par 

1     '    h 

gray  matt 

t                                    i: 

ing  was  ti 

seemed  to 

u      1       "     •         tl 

lies  at  a  h 

''H^H 

H              was  softe! 

■              exact  rep 

-'^i^l 

™               upon  the ; 

6 


tion,  for  his  pliilanthropy  and  warm-heartedness,  is  a 
feast  of  the  soul." 

Virchow's  life-work  has  been  the  study  of  the  pro- 
cesses of  disease,  and  in  the  profession  we  revere  him 
as  the  greatest  muster  that  has  appeared  among  us 
since  John  Hunter.  There  is  another  aspect  of  his  work 
which  has  been  memorable  for  good  to  his  native  city. 
From  the  day  when,  as  a  young  man  of  twenty-seven, 
he  was  sent  by  the  Prussian  government  to  Upper 
Silesia  to  study  the  typhus  epidemic,  then  raging 
among  the  half-starved  population,  he  has  been  one 
of  the  most  powerful  advocates  in  Germany  for 
sanitary  reform  ;  and  it  is  not  too  much  to  say  that 
it  is  largely  to  his  efforts  that  the  city  of  Berlin  owes 
its  magnificent  system  of  drainage.  His  work  in  this 
department  has  been  simply  moimmental,  and  charac- 
terized by  tlie  thoroughness  which  marks  the  specialist. 

To  his  exhaustive  monographs  on  camp-diseases, 
cholera,  military  medicine,  and  other  cognate  subjects, 
1  cannot  even  refer. 

It  will  be  generally  acknowledged  that  in  this 
country  doctors  are,  as  a  rule,  bad  citizens,  taking 
little  or  no  interest  in  civic,  state  or  national  politics. 
Let  me  detain  you  a  moment  or  two  longer  to  tell  of 
one  of  us,  at  least,  who,  in  the  midst  of  absorbing 
pursuits,  has  found  time  to  serve  his  city  and  bis 
country.  For  more  than  twenty  years  Virchow  has 
sat  in  the  Berlin  City  Council  as  an  alderman,  and  to 
no  feature  in  his  extraordinary  life  does  the  Berliner 
point  with  more  justifiable  pride.  It  is  a  combination 
of  qualities  only  too  rare,  when  the  learned  professor 
can  leave  his  laboratory  and  take  his  siiare  in  practical, 
municipal  work.  How  much  his  colleagues  have  ap- 
preciated his  efforts  has  been  shown  by  his  election  as 
Vice-president  of  the  Board ;  and  on  the  occasion  of 
the  celebration   in    1881,  the  Rathhnus  was  not  only 


■ 


[leartedneBs,  is  a 

tudy  of  the  pro- 
1  we  revere  him 
iart'd  amon^  us 
ipect  of  his  work 
I  hij  native  city. 
Df  twenty-seven, 
meiit  to  Up|)er 
ic,  tlien  raging 
le  has  been  one 
I  Germany  for 
lucli   to  say  tliat 

of  Berlin  owes 
lis  work  in  this 
tal,  and  charac- 
ks  tlie  specialist. 

cauip-diseases, 
ognate  subjects, 

d  that  in  this 
citizens,  taking 
lational  politics, 
longer  to  tell  of 
Ist  of  absorbing 
lis  city  and  his 
irs  Virchow  has 
tidermuii,  and  to 
oes  the  Berliner 
is  a  combination 
earned  professor 
larc  in  practical, 
eagues  iiave  ap- 
y  liis  election  as 
I  the  occasion  of 
us  was  not  only 


X    llj^ 


-h 


placed  at  the  disposal  of  the  committee,  but  the  ex- 
peuses  of  the  decorations,  etc.,  were  met  by  the  coun- 
cil ;  and  to-day  conies  word  by  cable  that  he  has  been 
presented  with  the  freedom  of  tiie  city. 

The  years  succeeding   to    Vjrchow's    student    days 
were  full  of  strong  political  feeling,  and  with  the  French 
Kevolution,  in  1848,  came  a  general  awakening.      I„ 
Germany  the  struggle  for  representative  government 
attracted  many  of  the  ardent  spirits  of  our  profession, 
and   It    was    then  that    Virchow    began    his    political 
career.      Ihe  revolution   was  a  failure,   and   brou.'ht 
nothing  to   the  young    prosector  but  dismissal   from 
us  public   positions.     His    participation    might   have 
been  condoned     had   he  not  issued  a  medico-political 
journal,   Die  Medicinische   Reform,    the    numbers  of 
which  are  even  now  very  interesting  reading,  and  con- 
tain  ideas  which   to  day  would   be  called    liberal,  but 
were  then  revolutionary.     It  is  a  striking  evidence  of 
the  deep  impression   which  even  at  that  time  Virchow 
had  made  upon  his  colleagues  and  the  profession,  that 
he  was  reinstated  in  his  otlice  at  the  urgent  solicitation 
of  the  medical  societies  of  the  city.     He  relates  in  his 
Gedachtmssrede  auf  Sc/wnktnr  who  was  the  Court 
physician  and  not  at  all  in  harmony  with  the  views  of 
his  prosector,  that  on  one  occasion  in  1848,  at  a  post- 
mortem, in   which  the  diagnosis  of   hajmorrhage  into 
the  brum  had  been  made  by  the  professor,   Virchow 
demonstrated  an  obstructing  embolus  in    tlie  artery 
Schdnlein  turned  to  him  in  a  half-vexed,  half-joking 
manner  and  said,  "Sie  selien  auch  ueberall  l^arrika- 
deu.       His  active  political  life  dates  from  18G2,  when 
he  was   elected  to  the  lower  house  from  one  of  the 
Berlin  districts,    and   has,    I  believe,  sat    as    member 
almost  continuously  from  that  date.     The  conditions 
111  Germany  have  not  been  favorable  to  a  man  of  ad- 
vanced liberal  views,  and  Virchow  has  been  attached 


n 


m 


I  'I 

i '  I 
i 


BALTIMO:?E 
JOHN    MURPHY    &.    C( 


t8 


91 


:J4 


it 


/  '•l^ 

'■I 
'  1 

tion  of  til 
at  any  ot) 
terior  pur 
gray  niatl 
ing  was  ti 
seoiuL'd  to 
lies  at  u  li 
was  sof'te 
exact  rep 
upon  the  ; 


8 


to  a  party  which  has  not  been  conspiciously  success- 
ful ;  but  he  has  been  an  honest  and  industrious  worker, 
a  supporter  of  all  measures  for  the  relief  of  the  i)eople, 
a  strenuous  opponent  of  ull  class  and  repressive  legisla- 
tion, and  above  all  an  implacable  enemy  of  absolutism 
as  personified  in  Bismarck.  A  man  of  such  strong  in- 
dividuality would  make  his  presence  felt  in  any  assem- 
bly ;  and  he  always  commanded  the  attention  of  his 
colleagues,  and  oftentimes  his  speeches  have  been  re- 
[)orled  fully  both  in  England  and  in  America. 

As  an  illustration  of  his  capacity  for  varied  work,  I 
recall  one  day  in  1884,  in  which  he  gave  the  morning 
demonstration  and  lecture  at  the  Pathological  Insti- 
tute, addressed  the  Town  Council  at  great  length  on 
the  extension  of  the  canalization  scheme,  and  made  a 
Budget  speech  in  the  House,  both  of  which  were  re- 
ported at  great  length  in  the  papers  of  the  next  day. 

Naturally,  amid  such  diverse  occupations,  ir  has 
been  impossible  for  him  to  enter  with  his  old  >  Igor 
into  the  minutiaj  of  pathological  anatomy,  and  his  atti- 
tude of  late  years  has  been  critical  rather  than  produc- 
tive ;  but  his  interest  in  all  that  pertains  to  our  profes- 
sion is  unabated,  and  is  a  feature  of  his  character  to 
which  I  must  allude.  Too  often  with  us,  in  our  gath- 
erings and  society  meetings,  the  "  men  of  rathe  and 
riper  years  "  are  conspicuous  by  their  absence.  In 
this  respect  our  great  master  has  set  a  notable  ex- 
ample. Amid  cares  and  worries,  social  and  political, 
with  a  thousand  and  one  ties  and  duties,  he  has  never 
held  aloof  from  his  brethren ;  but  as  the  weekly  medi- 
cal journals  testify,  no  man  in  Berlin  has  been  more 
active,  and  for  years  he  has  held  the  Presidency  of  the 
Berliner  Medicinische  Gessellschaft,  one  of  the  most 
important  medical  societies  of  Europe. 

Surely  the  contemplation  of  a  life  so  noble  in  its 
aims,  so   notable   in    its   achievements,   so   varied   in 


^K  // 


Jil 


iciously  success- 
U8ti'iou8  worker, 
ef  of  the  people, 
jpressive  logisla- 
ly  of  ubsolutism 
t  siicli  strong  in- 
It  in  any  assem- 
attentiou  of  his 
3s  liave  been  re- 
merica. 

r  varied  work,  I 
ive  tiie  morning 
;hological  Insti- 
Ijreat  length  on 
me,  and  made  a 
which  were  re- 
the  next  day. 
ipations,  it  has 
1  his  old  \i<;or 
uy,  and  his  atti- 
ler  than  produc- 
18  to  our  profes- 
lis  character  to 
us,  in  our  gath- 
I  of  rathe  and 
r  absence.  In 
a  notable  ex- 
1  and  political, 
!S,  he  has  never 
e  weekly  medi- 
has  been  more 
•esidency  of  the 
ue  of  the  most 


t 


us  pursuits  may  well  fill  m  with  admiration  for  the 

lar  reaching,  and  i,.  one  way  or  another  has  ,  f..)* 

^   each  o..e  of  us      It  is  well  to  acknowled  l«b 

wh  ch   we   evervHlay   practitioners   owe   to    >,       .  eat 
lea,ler8  and  workers  in  the  scienti.i.  brand  es  of'    ,! 

with  t^I  Jrv    i"  '""f'   ':'  -^•--''^'"'.  consume., 
witn  the  petty   cares   of  a  bread-and-butter  stru.r.rle 

S  wr„::v"''^  """i """"''  ''^  ki^^-  fiStu: 

7,    t       .  r      ,    ®  Professn.n  (and  you  of  the   public) 

&:::i,T^y  r^^y-  /^'''«  ie-o,f  which  shou  ii '  "^ 

Ivi? ,       ?  ""•'"  '"'"■''  '^  '''*^  «"«^^«'-  ^''icl'  'i  life,  .such 
aa  Vin.how's,  g.ves  to  those  who  to-dav,  as  in  nas   Jen 

medicine   and  who,  ut.hxing  the  gains  of  science   fail 

by  which  they  are  attained.     As  Puusanias  nestered 

"askil^..       ■",'  '"^  '\'''^  "'''  ^"h  us  still  those  who, 
.  asking  not  wisdom,  but  drugs  to  charm  with  "  «.« 

tZTT  '''.  «'"-  f!-Sres?  of  sciJnie,  fottt    g 
that  the  chaos   from  which  order  is  now  anpeari",«  h,f 

livIl-Kr^^  'T''^'  '>-V^'-  work  if '^oileMi;  . 
iiving  _  by  the  man  whom  to-night  we  delight  to  honor. 


so  noble  in  its 
,  so   varied   in 


BALTIMORE 

JOHN    MURPHY    &    CO. 

1891 


IMAGE  EVALUATION 
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WEBSTER,  N.Y.  14580 

(716)  872-4503 


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<^X   III 


DOCTOR  AND  NURSE 


Remarks  to  the  First  Class  of  Graduates  from  the 

Tr^-ining   School   for  Nurses  of  the 

Johns  Hopkins  Hospital 


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By   \yiLLlAM  OSLElt,   .M.  D. 

Physician-in-Ckief  to  the  Hospital 


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BALTIMORE 

JOHN    MURTHY    &    CO. 

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DOCTOR  AND  NURSE. 

Remarks  to  the  First  Ct  aqq  /^t^  n^ 

iriiL   riKhr  I.LASS   OF   GRADUATES  FROM 

THE  Training  School  for  Nurses  of  the 
Johns  Hopkins  Hospital. 

BY 

WILLIAM  OSLER,  M.  D., 

Physiciun-in-Chief  to  the  Hospital. 


Mr.  President,  Members  of  the  Board  of  Trus- 
tees, Members  of  the  Graduating  Class-Ladies 
and  (xentlemen : — 

There  are  individuals-doctors  and  nurses,  for 
example-whose  very  existence  is  a  constant  re- 
minder of  our  frailties  ;  and  considering  the  notori- 
ously irritating  character  of  such  people,  I  often 
wonder  that  the  world  deals  so  gently  with  them. 
The  parson  never  arouses  these  feelings-no  matter 
what  may  be  his  views  on  celestial  geography,  his 
cloth  and  tie  speak  of  dim  possibilities,  not  oV  the 
grim  realities  conjured  up  by  the  names  of  the  per- 
sons just  mentioned.    The  lawyer  never  worries  us- 
in  this  way.    We  can  imagine  in  the  future  a  social 
condition  in  which  neither  di  inity  nor  law  shall 


^^1 


have  a  place-wlien  all  shall  be  Friends  and  each 
one  a  I  rlest,  when  the  Meek  shall  possess  the 
eai-th;  but  Ave  cannot  picture  a  time  when  Birth 
and  Life  and  Death  shall  be  separated  from  the 
grizzly  troop,  which  we  dread  so  much,  and  which 
IS  ever  associated  in  our  minds  with  "  Dhvsiciin 
and  nurse." 

Broad!    Yes,  but  mercifully  for  us  in  a  va-^ue 
and  misty  way.     In  tlie  sl>ado,vs  cast  by  the  turi^ts 
of  tl.e  temple  of  oblivion,  towards  which  we  travel 
we  play  hke  schoolboys,  regardless  of  what  awaits 
us  m  the  vale  of  years  beneath.    Sufferins  and 
disease  are  ever  before  us,  but  life  is  very  pleasant; 
and  the  motto  of  the  world,  when  well,  i;  "forward 
with  the  dance."    Fondly  imagining  that  we  are 
ma  Hapi,y  Valley,  we  deal  with  ourselves  as  the 
King  did  with  Gautama,  and  hide  away  everythins 
that   suggests   our   fate.     Perhaps  we  are  wise 
M  ho  knows  ?    Mereifnlly,  the  tragedy  of  lite  thouMi 
seen  is  not  realized.     It  is  so  close  that  we  lose  all 
sense  of  its  proportions.    And  better  so;  for,  as  a 
great  philosopher  has  said,  "  if  we  had  a  keen  vision 
and  feeling  of  all  ordinary  human  life,  it  >,ould  be 
like  hearing  the  grass  grow,  or  the  squirrels  heart 
beat,  and  we  should  die  of  that  roar  which  lies  on 
the  other  side  of  silence." 

..Tff  °i™^'  '"''™^''''  "  ''  '"^  "''^"'  ■'""'•ness,  a 
sort  of  fool  s  paradise,  not  destroyed  by  a  thought, 
but  by  the  stern  exigencies  of  life,  when  the  "  mi„. 


lids  and  each 

possess  the 

when   Birth 

ed  from  tlie 

1,  and  which 

"  physician 

in  a  vague 
Y  the  turrets 
h  we  travel, 
what  awaits 
ffering  and 
•y  pleasant ; 
s  "  forward 
hat  we  are 
Ives  as  the 
everything 

are  wise, 
life  though 
we  lose  all 
' ;  for,  as  a 
:een  vision 
^  \v^ould  be 
I'el's  heart 
ch  lies  on 

indness,  a 
t  thought, 
he  "  min- 


isters  of  human  fate"  drag  us,  or-worse  still- 
those  near  and  dear  to  us,  upon  the  stage.     Then 
we  become  acutely  conscious  of  the  gre^t  drama  of 
human    suffering,   and   of  those  inevitable   stao-e 
accessories— doctor  and  nurse.  "  ° 

If,  Members  of  the  graduating  class,  the  medical 
profession,  composed  chiefly  of  men,  has  absorbed 
a    arger  share  of  attention  and  regard,  you  have, 
at  least,  the  satisfoction  of  feeling  that  yours  is  the 
older,  and,  as  older,  the  more  honorable,  callino- 
In  one  of  the  lost  books  of  Solomon,  a  touchiirJ 
pic  lire   IS  given   of  Eve,   then   an   early   grand! 
mother,  bending  over  the  little  Enoch,  and  show- 
ing   Mahala   how  to  soothe  his  sufferings  a-      to 
allay  his  pains.     Woman,  "the   link   among  tne 
days,"  and   so  trained  in  a  bitter  school,  has    in 
successive  generations,  played  the  part  of  Mahala 
to   the   little   Enoch,   of  Elaine  to   the  wounded 
Lancelot.     It  seems  a  far  cry  from   the  plain  of 
Mesopotamia   and    the   lists    of   Camelot    to   the 
Johns   Hopkins    Hospital,   but   the    spirit   which 
makes  this  scene  possible  is  the  same,  tempered 
through    the    ages,    by   the    benign    influence   of 
Christianity.     Many  among  the  ancients  had  risen 
to  the  Ideas  of  forgiveness  of  enemies,  of  patience 
under  wrong  doing,  and  even  of  the  brotherhood 
of  man ;   but  the  spirit  of  Love  only  received  its 
incarnation  with  the  ever  memorable  reply  to  the 
ever  memorable  question,  Who  is  my  neighbor  9-a 


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reply  which  has  changed  the  attitude  of  the  workl 
Nowhere  in  ancient  history,  sacred  or  protane,  do 
we  find  pictures  of  devoted  heroism  in  woman  such 
as  dot  the  annals  of  the  Catholic  Church,  or  such 
as  can  be  paralleled  in  our  own  century.  Tender 
maternal  affection,  touching  filial  piety  were  there  • 
but  the  spirit  abroad  was  that  of  Deborah  not 
Itizpah,  of  Jael  not  Dorcas. 

In  the  gradual  division  of  labor,  by  which  civil- 
ization  has  emerged  from  barbarism,  the  doctor 
and  the  nurse  have  been  evolved,  as  useful  acces- 
sories  in  the  incessant  warfare  in  which  man  is 
engaged.  The  battle  is  ever  against  him,  for  the 
worst  foes  are  in  his  own  household 

Collectively,  man,  the  race,  with  passions  and 
ambitions,  weaknesses  and  vanities,  has  made,  by 
barbaric  inhumanity,  countless  thousands  mourn 
and  even  to-day,  when  philosophers  would  have  us 
believe  his  thoughts  have  widened,  he  is  ready  as 
of  old  to  shut  the  gates  of  mercy,  and  to  let  loose 
the  dogs  of  war.     It  was  in  one  of  these  attacks  of 
race-mania  that  your  profession,  until  then  unset- 
tled and  ill-defined,  took,  under  Florence  JVight- 
eng^le-ever   blessed  be  her   name-its  modern 
position. 

Individually,  man,  the  unit,  the  microcosm,  fast 
bound  m  chains  of  atavism,  inheriting  not  alone 
feature  and  form,  but  legacies  of  feeble  will  and 
strong  desires,  taints  of  blood  and  braln-what 


f  tlio  world, 
profane,  do 
vonian  such 
'ch,  or  such 
y.  Tender 
wore  there ; 
eborah   not 

vhich  civil- 
tho  doctor 
eful  acces- 
ch  man  is 
im,  for  the 

ssions  and 
made,  by 
Is  mourn; 
[d  have  us 
5  ready  as 
>  let  loose 
attacks  of 
ien  unset- 
3e  Night- 
i  modern 

!osm,  fast 
lot  alone 
will  and 
in — what 


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wonder  that  many,  soro  let  and  hind.M-ed  in  run- 
ning-  the  race,  tall  by  the  way,  and  need  a  shelter 
in  whidi  to  recruit  or  to  die;  a  hospital,  in  which 
there  shall  be  no  harsh  comments  on  conduct,  luit 
only,  so  tar  as  is  possible,  love  and  peace  and  rest 
Here,  we  learn  to  scan  gently  our   brother  man 
and-chief  test  of  charity  in  your  sex-stiU  o.entler 
sister  woman;  judging  not,  asking   no  quastions, 
but  metmg  out  to  all  alike  a  hospitalitv  worthy  of 
the  Hotel  Dieu,  and  deeming  ourselves  honored  in 
being  allowed  to  act  as  its  disixMisors.     Here  too 
are  daily  before  our  eyes  the  problems  which  'have' 
ever  perplexed   the   human   mind;   problems  not 
presented  in  the  dead  abstract  of  books,  but  in  the 
livmg   concrete   of  some   poor   fellow  in   his  last 
round,  fighting  a  br.^^e  fight,  but  sadlv  weio-hted 
and  gomg  to  his  accoi  nt  "  unhousel'd,  di'sappohited' 
unaneled,  no  reckoning  made."     As  we  whisper  to 
each  other  over  his  bed  that  the  battle  is  decided 
and  Euthanasia  alone  remains,  have  I  not  heard  in 
reply  to  that  muttered  proverb,  so  often  on  the  lips 
of  the  physician,   "the   fathers   have  eaten   sour 
grapes,"  your  answer,  in  clear  accents,— the  com- 
forting words  of  the  prayer  of  Stephen  ? 

But  our  work  would  be  much  restricted  were  it 
not  for  man's  outside  adversary-Nature,  the  great 
Moloch,  which  exacts  a  frightful  tax  of  human 
blood,  sparing  neither  young  nor  old ;  taking  the 
child  from  the  cradle,  the  mother  from  her  babe 


I     I 


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and  the  father  from  the  family.     Is  it  strange  tliat 
man,  unable  to  dissociate  a  personal  element  from 
such   work,   has   incarnated   an  evil   principle— a 
devil  ?    If  we  have  now  so  tar  outgrown  this  ideli 
as   to  hesitate  to  suggest,  in  seasons  of  epidemic 
peril,  that  "  it  is  for  our  sins  we  suffer, "—when  we 
know  the  drainage  is  bad ;  if  we  no  longer  mock 
the  heart  prostrate  in  the  grief  of  loss  with  the 
words  "  whom  the  Lord  loveth  he  chastoneth  "— 
when  we  know  the  milk  should  have  been  steril- 
ized—if,   I  say,  we  have,  in  a  measure  become 
emancipated  from  such  teachings,  we  have  not  yet 
risen  to  a  true  conception  of  Nature.     Cruel,  in  the 
sense  of  being  inexorable,  she  may  be  called,  but 
we  can  no  more   upbraid  her   laws  than  we'  can 
those  of  the  state,  which  are  a  terror  only  to  evil 
doers  ;  and  so  it  is  with  the  greater  laws  of  Nature. 
The  pity  is  that  we  do  not  know  them  all ;  in  our 
ignorance  we  err  daily,  and  pay  dearly  a  blood 
penalty.     Fortunately  it  is  now  a  great  and  grow- 
ing  function  of  the  medical  profession  to  search  out 
the  laws  about  epidemics,  and  these  outside  ene- 
mies of  man,  and  to  teach  to  you,  the  public— dull 
stupid  pupils  you  are,  too,  as  a  rule— the  ways  of 
Nature,  that  you  may  walk  therein  and  prosper. 

It  would  be  interesting,  members  of  the  gradu- 
ating  class,  to  cast  your  horoscopes.  To  do  so 
collectively  you  would  not  like;  to  do  so  indi^ 
vidually-I   dare   not;   but  it  is   safe  to  predict 


9 


certain  thino-s  of  you,  a.  a  wliolo.     You  will   he 
better  women  for  the  life  which  you  have  led  here 
AI   women  are  g(,od,  naturally;  the  bad  are  made 
so  by  men.     IJut  what  I  mean  by  -  better  women  " 
IS  that  the  eyes  of  your  souls  have  been  opened 
tiie  range  of  your  sympathies  has  been  widened 
and   your  characters  have  been  moulde<l  l)v  the' 
events  in  which  you  have  been  participators  dur- 
ing the  past  two  years. 

Practically   there    should    be   for   each   of   vou 
a  busy,  useful,  and  happy  life ,  more  you  can'not 
expect ;  a  greater  blessing  the  world  cannot  bestow 
iiusy  you  shall  certainly  bo,  as  the  demand  is  o-reat 
both  in  private  and  public,  for  women  with  your 
training.     Useful  your  lives  shall  be,  as  you  will 
care  for  those  who  cannot  care  for  themselves,  and 
who  need  about  them,  in  the  day  of  tribulation 
gentle  hands  and  tender  hearts.     And  happy  lives' 
shall  be  yours,  because  busy  and  useful ;  havin- 
been  initiated  into  two  of  the  three  mysteries  of 
the  Great  Secret-that  happiness  lies  in  the  absorp- 
tion  in  some  vocation  which  satisfies  the  soul  •  that 
we  are  here  to  add  what  we  can  to,  not  to  get' what 
wecan/r()m,  Life,-  and  the  third,--is  still  a  mvstery 
which  you  may  or  may  not  learn  hereafter.  ' 
Of  the  aims  of  the  Founder  and  Trustees  of  this 


Hospital,  one  has  be 


•een  carried  out  during-  tl 


two  years,  in  which,  in  the  wards  and  dis°p 


le  past 


over  33,000  sick  received  aid 


'les, 


_  ensar 
another  is  accom 


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10 

plished  to-day  in  the  granting  of  these  diplomas 
and  we  await  the  completion  of  these  aims  in  the 
establishment  of  the  medical  school. 

Let  me  congratulate  you  as  the  iirst  of  the  goodly 
bands  which,  year  by  year,  shall  distribute  tar  and 
wide  the  blessings  of  this  Institution. 

I  may  express,  Mr.  President,  on  behalf  of  your 
medical  staff,  our  gratification  at  the  success  of  the 
1  raining  School  and  our  appreciation  of  the  charac- 
ter of  the  work  that  has  been  done-in  every  respect 
m  keeping  with  the  high  standard  expected  by  the 
profession,  the  ci^y  and  the  country.     I  have  been 
a  hospital  physician  long  enough  to  have  watched 
the  vrrious  steps  in  the  evolution  of  the  trained 
nurse,  and   can  speak  of  the  value  of  the  great 
change  which  has  been  made.    I  can  assure  you  Sir 
and  the  Members  of  the  Board  of  Trustees,  'that 
the  sick,  for  whose  welfare  you  have  been,  through 
your  deputies,  directly  responsible,  have  received 
at  the  hands  of  these,  your  graduates,  every  con- 
sideration,  kindness  and  attention,-not  that  per- 
functory, routine  care  which  strains  the  very  c,ualitv 
of  mercy,  but  an  interested  devotion  worthy  of  the 
spirit  which  we  hope  shall  always  characterize  the 
woik  of  this  place. 

And  let  me  assure  you,  members  of  the  gradu 
ating  class,  that  although  you  go  away  out  of  our 
iives  and  that  of  the  Institution,  you  still  belonc. 
to   us,   and   your   welfare   is   our   happiness.     In 


11 

worries  and  anxieties  of  mind  or  of  bodv  it  ,vill 
l>e  a  privilege  and  a  pleasure  to  help  vou  ' 

And    finally,    remember   «hat   we'    are-useful 
supernumeraries  in  the  battle,  simply  staee  aoces- 
sones  in  the  Drama,  plaH„g  minor,' but  I^sential 
parts  at  the  exits  and  ent..,nces,  or  piekin^-up,  her 
-Hhere,  a  strutter,  .ho  m,.y  have  .rippec!'u,.„ 

You  have  been  much  by  the  dark  river-so  near 
to  usall-and  have  seen  so  many  embark,  that  vou 
now  know  the  old  boatman  too  well  to  dread  him';  so 

"  When  the  Aiigel  of  the  darker  Drink 
At  last  shall  find  you  by  the  river  brink, 
And  offering  his  cup,  iavite  your  soul 
Forth  to  your  lips  to  quaif-you  sliall  n„t  shrink  "_ 

And  why  should  you  ?  Your  passport  shall  be  the 
blesstng.  of  am  in  who.e  footsteps  you  have  trodden, 
un  0  whose  sick  you  have  ministered,  and  for  whose 
children  you  have  eared. 


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mess.     In 


